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THE 


General  Practitioner 


AS  A 


Specialist 


A  Treatise    Devoted  to  the  Consideration  of 
Medical    Specialties 


BY 

J.  D.  ALBRIGHT,  M.  D. 


Third  Edition 
Revised,  Enlarged  and  Illustrated 


PUBLISHED  BY  THE  AUTHOR 


PHILADELPHIA,    PENNSYLVANIA 
I904 


COPYRIGHTED  BY 

J.  D.  ALBRIGHT,  M.  D. 
1904. 

ALL,  RIGHTS  RESERVED. 


PREFACE  TO  THE  THIRD  EDITION. 


The  complete  exhaustion  of  former  editions  of  this  work 
has  rendered  the  publication  of  this,  the  Third  edition, 
necessary. 

The  sense  of  a  well  defined  feeling  of  uncertainty  present 
when,  thirty  months  ago,  the  Second  edition  of  several 
thousand  copies,  was  launched  into  a  comparatively  unex- 
plored sea,  is  at  this  time  agreeably  absent.  The  cordial 
reception  extended  former  editions  and  the  many  letters  of 
approbation  and  encouragement  received,  give  instead  the 
assurance  of  a  continuation  of  good  will  and  support.  That 
this  volume  will  merit  the  approval  of  those  into  whose 
possession  it  may  come,  is  my  most  sincere  wish. 

Taking  advantage  of  the  opportunity,  the  extent  of  the 
work  has  been  somewhat  enlarged ;  new  matter  has  been 
added  and  certain  subjects  have  been  more  thoroughly 
considered.  Several  illustrations,  reproduced  from  original 
photographs,  are  also  a  new  feature. 

As  many  of  the  methods  of  treatment  are  to  a  certain 
extent,  an  evolution,  developed  to  their  present  state  of 
perfection  by  the  combined  efforts*  of  several  minds  following 
the  same  course,  proper  credit  cannot  easily  be  given.  I 
have,  however,  made  an  effort  to  give  credit  in  the  text  for 
suggestions  and  assistance,  wherever  due. 

Should  I  have  failed  in  thi?  ;  by  oversight  neglected  one, 
or  overlooked  another,  let  him  accept  this,  my  expression 
of  thanks  cheerfully  acknowledged. 

'3 


Dr.  T.  W.  Williams,  of  Milwaukee,  Wis.,  has  con- 
tributed the  chapters  under  his  name,  to  whom  inquiries  con- 
cerning the  same  should  be  addressed. 

Continuing  my  former  policy,  I  will  be  pleased  to 
correspond  or  co-operate  with  any  physician  into  whose 
hands  this  may  come,  recognizing  the  mutual  benefits  that 
accrue  from  combined  efforts  and  exchange  of  ideas,  and 
that,  if  the  fates  so  decree,  greater  good  may  be  accom- 
plished. "For  this  was  the  manner  in  former  time  in  Israel. 
*  *  *  for  to  confirm  all  things,  a  man  plucked  off  his 
shoe  and  gave  it  to  his  neighbor." 

THE  AUTHOR. 

Philadelphia,  Pa. 
January  1904. 


PREFACE  TO  THE  SECOND  EDITION. 


The  gratifying  reception  accorded  the  first  edition  of 
this  work  by  the  medical  profession  throughout  the  United 
States  and  Canada,  as  evidenced  by  the  hundreds  of  com- 
mendatory letters  received  and  the  rapid  exhaustion  of  the 
entire  edition,  has  prompted  the  author,  in  preparing  the 
second  edition,  to  revise  and  considerably  enlarge  it. 

In  addition  to  the  matter  contained  in  the  first  edition, 
the  author  has  complied  with  the  general  demand  for  further 
and  more  detailed  consideration  of  some  of  the  subjects 
therein  treated,  and  has,  in  addition  thereto,  added  chapters 
devoted  to  the  consideration  of  other  specialties. 

During  the  past  year  the  author  has  investigated  and 
purchased  a  number  of  the  more  recent  Secret  Systems, 
advertised  and  sold  to  the  medical  profession,  all  of  which 
are  disclosed  in  this  edition. 

The  author  wishes  to  acknowledge  valuable  suggestions 
and  assistance  from  Drs.  R.  St.  J.  Perry,  C.  L.  Dana,  F.  W. 
McCanon  and  E.  L.  Goodall ;  also  from  the  writings  of 
Agnew,  Waugh,  Monroe  and  others  who  have  received  due 
credit  throughout  the  work. 

Thanking  the  profession  for  their  liberal  expressions 
of  appreciation  and  substantial  support,  the  author  hopes  to 
merit  their  continued  approbation. 

The  author  will  be  pleased  to  correspond  or  co-operate 
with  any  physician  into  whose  hands  this  may  come. 

July  ist,  1901. 


INTRODUCTORY  TO  FIRST  EDITION, 


To  that  large  body  of  energetic  and  progressive  physi- 
cians who  have  learned  to  recognize  the  value  of  concen- 
trated effort  in  any  one  direction,  and  who  appreciate  the 
exceptional  advantages  to  be  derived  from  the  use  of  meri- 
torious remedies  and  methods  of  treatment,  this  work  is 
respectfully  offered. 

To  such,  no  apology  is  necessary,  as  it  will  fill  a  vacancy 
that  has  long  been  known  to  exist;  no  work  of  the  kind 
having  ever  before  been  placed  at  their  disposal. 

To  the  minority  of  the  profession,  those  who  are  con- 
tented with  their  quarter  and  half  century-old  methods  and 
ideas,  and  who  without  investigation  unhesitatingly  condemn 
progress  in  every  form  and  wherever  found,  this  work  will 
not  appeal. 

If  the  highly  gratifying  results  attainable  by  the  use  of 
the  information  detailed  in  the  following  pages  be  a  criterion, 
no  one  will  hesitate  to  credit  the  statement  that  it  embodies 
the  latest  and  most  advanced  ideas  now  employed  by  the 
leading  specialists  in  their  respective  lines  of  work. 

That  it  will  be  the  means  of  accomplishing  "the  greatest 
good  to  the  greatest  number,"  thereby  bringing  health  and 
happiness  to  the  patient  and  professional  and  financial  suc- 
cess to  the  physician,  is  the  wish  of 

THE  AUTHOR. 

May,   1900. 


DISEASES  OF  THE   RECTUM 

AND  ANUS. 


In  these  days  of  Specialism,  when  so  large  a  number 
of  general  practitioners  are  deserting  the  ranks  to  seek  fame 
and  fortune  along  the  lines  of  specialties,  it  is  somewhat 
strange  that  the  extensive  and  fertile  field  of  Rectal  Diseases 
is  so  frequently  overlooked  and  so  generally  avoided.  There 
is  no  specialty  in  medicine  in  which  the  material  is  so  plenti- 
ful ;  the  indications  for  treatment  so  clearly  defined ;  the 
results  so  generally  satisfactory ;  the  patients  so  uniformly 
grateful,  and  the  opportunities  for  revenue  so  excellent. 

No  part  of  the  body  is  more  prone  to  disease  than  the 
rectum,  and  there  are  no  diseases  which  as  a  class  are  less 
understood.  There  are  no  diseases  so  uniformly  annoying 
and  painful,  and  none  so  silently  and  submissively  endured. 

In  former  years,  aside  from  the  employment  of  purely 
surgical  means,  the  regular  medical  profession,  with  but 
few  exceptions,  devoted  but  little  time  and  attention  to  the 
treatment  of  diseases  of  the  rectum  and  anus,  consequently 
a  large  portion  of  this  practice  passed  into  the  hands  of 
itinerants  and  charlatans,  who  have  ever  been  alert  to  take 
advantage  of  opportunities  neglected  by  the  profession. 

If  there  were  any  ground  for  the  opinion.  I  have  heard 
expressed,  that  the  treatment  of  rectal  diseases  suggested  a 
lack  of  dignity,  it  would  probably  be  found  to  spring  from 
the  impressions  made  by  the  disreputable  men  and  methods 
formerly  associated  in  this  branch  of  medicine.  The  title 
"traveling  pile  doctor"  certainly  implies  no  dignity  and  less 
honor,  but  the  legitimate  rectal  specialist  is  not  to  be  men- 
tioned in  comparison  and  bears  no  relation  to  him  whatever. 

7 


8  DISEASES  OF  THE 

The  impression  that  rectal  work  is  unclean  and  unpleasant 
is  probably  a  strong  factor  in  influencing  a  physician  to 
adopt  some  other  line  of  work,  yet  this  should  have  but  little 
weight  when  one  considers  it  in  comparison  with  genito- 
urinary, gynecological  or  obstetrical  work. 

Persons  of  ordinary  intelligence  and  the  usual  sense  of 
delicacy  will  foresee  the  desirability  of  cleanliness,  and  in 
their  behalf  it  must  be  said,  the  external  appearance  of  filth 
is  but  rarely  noticed. 

Granting  that  prior  to  the  inauguration  of  stringent 
medical  legislation,  the  country  was  infested  with  "traveling 
pile  doctors,"  whose  ignorance  prevented  them  from  treat- 
ing rectal  diseases  except  for  revenue  only,  we  must  admit 
that  the  irregular  rectal  specialists  of  to-day  are  not  in  their 
class.  As  stated  in  an  editorial  in  the  Medical  Record,  "the 
modern  irregular  practitioner  is  less  of  a  fool  and  an  igno- 
ramus than  his  predecessor.  He  is  sometimes  a  man  of  good 
medical  education  and  experience."  Regular  practitioners 
entering  this  field  have  in  the  modern  irregular  specialist  a 
competitor  worthy  of  their  steel,  yet  by  their  methods  of 
awakening  interest  among  persons  afflicted  with  rectal  dis- 
eases, the  regular  practitioner  is  benefited. 

This  fact  is  perhaps  responsible  for  the  interest  that 
has  been  aroused  and  which  is  apparent  on  all  sides,  as 
evidenced  by  the  attention  that  is  now  being  directed  toward 
this  class  of  diseases,  as  well  as  the  treatment  of  hernia  by 
the  injection  method,  the  treatment  of  cancers,  etc.,  all  of 
which  have  for  many  years  been  practically  in  the  hands  of 
the  irregulars. 

As  I  stated  in  an  article  published  in  the  Medical  Brief, 
in  December,  1898,  on  the  importance  of  directing  attention 
toward  specialties,  "Show  me  a  branch  in  which  the  special- 
ist or  'institute'  thrives,  and  I  will  show  you  a  branch  which 
the  general  practitioner  has  neglected." 

However,  if  "straws  indicate  the  course  of  the  wind," 
and  unless  all  signs  fail,  the  end  of  another  decade  will  find 
the  majority  of  the  medical  profession  strongly  advocating 


RECTUM    AND    ANUS.  9 

and  diligently  practicing  many  means  and  methods  which 
to-day  are  strenuously  opposed  and  possibly  denounced  by 
many  of  them.  The  change  of  attitude  toward  the  non-sur- 
gical treatment  of  rectal  diseases  is  demonstrated  by  the 
many  leading  articles  that  appear  in  high  grade  medical  pub- 
lications, written  by  men  of  high  professional  standing  and 
of  excellent  repute. 

The  treatment  of  hemorrhoids  constitutes  the  major 
portion  of  the  work  of  the  rectal  specialist,  yet  as  he  treats 
these  cases  successfully  he  will  naturally  be  led  to  the  inves- 
tigation and  treatment  of  other  forms  of  rectal  diseases,  by 
virtue  of  the  close  relationship  existing  between  different 
diseases.  Before  passing  on  to  the  consideration  of  the  sev- 
eral diseases  that  appear  in  the  rectum,  the  advantages  and 
disadvantages  of  the  injection  treatment  of  hemorrhoids, 
quoting  several  writers,  will  be  reviewed,  as  to  the  inexperi- 
enced, or  possibly  prejudiced,  mind  there  is  nothing  so  con- 
vincing as  evidence. 

If  it  were  not  a  matter  of  regret  that  so  strong  a  preju- 
dice could  exist  in  so  honorable  and  respected  a  profession, 
it  would  be  amusing  to  record  the  objections  that  physicians 
opposed  to  this  method  of  treatment  offer  against  it.  I 
have  before  me  a  clipping  from  a  Western  medical  journal, 
written  by  a  Professor  of  Surgery  in  a  medical  college  of 
the  West,  in  which  he  says :  "If  sloughing  takes  place  after 
the  injection  of  carbolic  acid  into  a  pile  tumor,  it  will  prob- 
ably be  from  throwing  the  fluid  through  the  vein  into  the 
areolar  tissue  beneath.  Knowing  this  to  be  the  case,  I  was 
very  careful  not  to  do  this,  but  the  sloughing  came  just  the 
same."  Later  on  he  states  that  the  solution  used  was  16% 
carbolic  acid  and  "this  sloughing  I  consider  one  of  the  most 
serious  objections  to  this  mode  of  treating  piles."  I  should 
very  much  like  to  know  how  or  by  what  means  he  expected 
the  tumor  to  disappear. 

When  sloughing  is  limited  to  the  tumor  which  is  dead- 
ened by  the  injection  of  a  proper  fluid,  no  danger  to  the 
patient  can  exist,  neither  will  it  cause  any  inconvenience,  but 


lO  DISEASES   OF   THE 

if  the  sloughing  involves  the  bowel,  the  fluid  was  either 
improperly  injected  or  the  proper  fluid  was  not  used.  Pos- 
sibly from  inexperience  he  lacked  the  proper  skill  necessary 
to  inject  the  fluid  properly,  and  as  he  was  probably  seeking 
evidence  to  condemn  the  treatment,  he  used  a  solution  of 
only  16%  of  carbolic  acid  strength ;  too  weak  to  cauterize 
and  prevent  absorption,  and  a  great  deal  weaker  than  is 
used  by  the  successful  practitioners  using  this  method.  It 
is  more  than  passing  strange  that  a  man,  generally  well 
informed,  should  attempt  to  instruct  others  in  a  subject  con- 
cerning the  principles  of  which  he  is  comparatively  ignorant. 
In  a  review  of  the  comments  of  prominent  physicians  who 
are  opposed  to  the  non-surgical  treatment  of  the  rectum, 
notably  the  injection  treatment  of  hemorrhoids,  the  follow- 
ing objections  seem  to  be  the  most  general: 

i.  Danger.  Andrews  of  Chicago  has  reported  a  num- 
ber of  deaths  due  to  the  sequences  following  the  injection  of 
certain  fluids  into  hemorrhoids,  but  he  fails  to  state  the 
number  of  persons  who  have  died  from  the  effects  of  surgi- 
cal operations  for  the  relief  of  similar  conditions ;  neither 
did  he  employ  a  fluid  such  as  is  now  considered  the  only 
rational  and  proper  one  to  inject  into  hemorrhoidal  tumors. 
The  indiscriminate  injection  of  irritating  fluids  has  never 
received  the  sanction  of  the  successful  physicians  using  this 
method,  and  carelessness  in  injecting,  so  often  combined 
with  the  use  of  an  improper  fluid,  cannot  be  expected  to 
produce  satisfactory  results.  The  use  of  a  suitable  fluid, 
properly  injected,  is  uniformly  curative  and  is  as  free  from 
danger  and  serious  consequences  as  the  lancing  of  a  felon 
or  the  extraction  of  a  tooth. 

2.  .  It  is  not  uniformly  curative.  This  objection  would 
be  a  poor  one  if  it  were  true,  but  it  is  not  true.  With  the 
exception  of  cutaneous  external  hemorrhoids  the  treatment 
is  absolutely  curative,  if  the  proper  fluid  is  employed  and 
carefully  injected.  The  surgical  operation  for  hemorrhoids 
is  not  only  not  uniformly  curative,  but  in  many  cases  the 
results  of  the  operation  are  far  worse  than  the  original  condition. 


RECTUM   AND  ANUS.  II 

3.  It  is  a  tedious  treatment.  This  objection  is  not 
well  taken.  Patients  prefer  mild  means  to  severe  ones  and 
if  a  choice  were  offered  them,  the  large  majority  would  pre- 
fer a  slow  but  certain  cure  to  a  speedy  operation  of  which 
the  outcome  is  uncertain. 

4.  It  is  not  applicable  to  all  piles.  This  is  true.  No  one 
ever  claimed  that  all  external  piles  should  be  injected.  The 
injection  treatment  is  principally  a  form  of  treatment  for 
internal  piles,  and  as  such  it  is  a  decided  success. 

On  the  other  hand,  prominent  advocates  of  this  method 
have  this  to  say  against  the  ligature,  clamp  and  cautery,  and 
the  knife. 

Dr.  S.  S.  Turner.  U.  S.  Army,  says  :  "Mr.  Whitehead's 
operation  is  so  self-evidently  bloody,  tedious  and  difficult 
that  no  general  practitioner  and  few  specialists  will  care  to 
undertake  it.  Xo  amount  of  assertion  by  Mr.  Whitehead 
in  favor  of  its  simplicity,  will  deceive  any  one  who  has 
studied  anatomy." 

Allingham  says  of  the  clamp  and  cautery,  "In  my  opin- 
ion it  has  little  to  recommend  it.  As  far  as  my  most  careful 
researches  have  led  me  to  a  conclusion,  it  is  quite  six  times 
as  fatal  as  the  ligature  properly  and  dextrously  applied." 

Dr.  Haynes  says  of  the  ligature,  "I  have  frequently 
made  Allingham's  ligature  operation.  It  is  easy  and  effect- 
ual, but  followed  by  retention  of  urine  and  great  pain,  lasting 
in  some  cases  seven  days.  One  of  my  cases  died  from  lock- 
jaw and  a  similar  result  followed  a  case  in  the  Episcopal 
•Hospital  in  Philadelphia." 

Dr.  J.  W.  Hallum,  in  an  article  in  a  leading  medical 
journal,  says:  "The  treatment  of  hemorrhoids  by  carbolic 
acid  injection  is  a  method  that  I  hesitate  to  present  and  advo- 
cate, not  because  of  its  defects,  but  on  account  of  its  oppo- 
nents." He  further  says  that  in  ten  years'  practice  of  the 
method,  he  has  never  had  any  alarming  symptoms,  no 
■secondary  hemorrhage  and  no  sloughing  other  than  the 
pile  itself,  and  without  a  single  failure. 


12  DISEASES   OF    THE 

The  honor  of  being-  the  originator  of  the  injection 
method  of  treating  hemorrhoids  has  been  accorded  to  Colles 
of  Dublin,  who  first  employed  the  method  in  1874,  although 
he  was  closely  followed  by  Sturgeon  of  this  country,  who 
practiced  the  same  method  the  same  year. 

Agnew  of  San  Francisco  reported  cures  by  this  method 
as  early  as  1877,  and  has  been  employing  it  with  success  ever 
since. 

Numerous  others  could  be  mentioned  who  have  prac- 
ticed the  method  for  over  twenty  years. 

Those  of  the  profession  who  imagine  that  this  mode  of 
treating  hemorrhoids  is  still  in  a  crude  and  imperfect  state, 
and  that  the  perhaps  unsatisfactory  results  obtained  by  a  few 
isolated  and  inexperienced  practitioners  are  a  criterion  by 
which  the  value  of  the  treatment  is  measured,  are  laboring 
under  a  delusion  and  existing  in  a  state  of  lethargy  from 
which  they  cannot  emerge  too  quickly. 

The  close  relationship  existing  between  different  forms 
of  diseases  of  the  rectum  and  anus,  many  of  which  resemble 
each  other  so  closely  that  the  differential  diagnosis  is  not 
always  easy,  and  as  the  treatment  of  one  disease  often  neces- 
sitates the  treatment  of  others,  those  coming  within  the  scope 
of  this  work  will  be  considered.  Those  of  a  malignant 
nature  will  be  omitted. 

The  diseases  of  the  rectum  and  anus  which  can  be  suc- 
cessfully treated  by  the  general  practitioner  may  be  said  to 
be,  Hemorrhoids,  Rectal  L'lcers,  Rectal  and  Anal  Fissure, 
Rectal  and  Anal  Fistula,  Rectal  Polypus  and  Prolapse  of  the 
Rectum.  In  connection  with  these  may  be  included  the 
treatment  of  Pruritus,  Eczema  and  Constipation. 

Each  of  these  will  receive  attention  in  their  order, 
special  attention  being  given  to  diagnosis  and  treatment. 
Works  on  anatomy  are  at  the  disposal  of  all  practitioners, 
and  a  lengthy  anatomical  description  of  the  rectum  and  a 
histological  and  pathological  study  of  its  structure  in  health 
and  disease  could  serve  no  purpose  in  a  work  of  this  nature. 


RECTUM   AND  ANUS.  1 3 

Enough  of  this  will,  however,  be  given  to  place  the  subject 
clearly  before  the  reader.  A  complete  and  exhaustive  study 
of  the  anatomy  of  the  parts  will  amply  repay  the  practitioner 
for  the  time  and  labor  so  spent. 


Hemorrhoids. 


Hemorrhoids  are  usually  defined  as  tumors  largely 
composed  of  varicose  or  dilated  veins  of  the  lower  part  of 
the  rectum,  surrounded  and  infiltrated  by  connective  tissue. 
This  is  correct  with  the  exception  that  the  arteries  may  be 
also  involved.  Hemorrhoids  are  divided  into  two  general 
classes,  Internal  and  External.  This  classification  has  an 
anatomical  and  pathological  basis  and  serves  as  a  guide  to 
treatment.  Internal  hemorrhoids  originate  and  have  their 
attachments  above  the  external  sphincter  and  are  within  the 
grasp  of  this  muscle.  External  hemorrhoids  have  their 
origin  in  the  anal  membrane  or  at  the  muco-cutaneous  junc- 
tion, and  when  the  sphincter  is  closed,  are  external  to  it. 
Internal  hemorrhoids  when  of  sufficient  size,  protrude 
through  the  sphincter  during  straining,  but  they  may  be 
returned  into  the  bowel,  where  they  will  remain  until  again 
forced  down.  External  hemorrhoids  cannot  be  forced  into 
the  bowel,  but  remain  constantly  on  the  outside.  It  is  as 
a  rule  not  difficult  to  make  a  diagnosis  between  internal  and 
external  piles,  but  it  is  important  that  it  should  be  correctly 
made,  as  the  treatment  of  the  two  forms  is  essentially  differ- 
ent. 


14  DISEASES    OF    THE 

Internal  hemorrhoids  are  subdivided  into  three  varieties 
and  are  named  according  to  their  character,  the  Venous, 
Capillary  and  Arterial.  Different  writers  have  mentioned 
many  other  varieties,  named  according  to  their  shape  and 
characteristics,  but  it  is  unnecessary  to  mention  them  as 
their  treatment  is  practically  the  same. 

External  hemorrhoids  are  divided  into  two  classes,  the 
Venous  and  Cutaneous.  The  former  are  again  subdivided 
into  the  varicose  and  the  thrombic.  The  Cutaneous  are 
also  again  divided  into  the  redundant,  the  hyperplastic  and 
the  hypertrophic. 

Mixed  hemorrhoids  may  also  exist,  partly  within  the 
sphincter  and  partly  without. 

The  rectum  receives  its  blood  supply  from  the  superior, 
middle  and  inferior  hemorrhoidal  arteries.  The  superior 
hemorrhoidal  is  a  continuation  of  the  inferior  mesenteric, 
and  by  a  number  of  branches  descends  between  the  mucous 
and  muscular  coats  of  the  rectum  nearly  as  far  as  its  lower 
end,  anastomosing  with  each  other,  with  the  middle  and  the 
inferior  hemorrhoidal  arteries.  The  middle  hemorrhoidal 
artery  is  a  branch  of  the  anterior  trunk  of  the  internal  iliac 
and  supplies  the  lower  part  of  the  rectum,  anastomosing 
with  the  others.  The  inferior  hemorrhoidal  arteries  are  two 
or  three  in  number,  arising  from  the  internal  pudic.  They 
supply  the  sphincters  and  integument  of  the  anal  region. 

The  veins  of  the  rectum  are  the  superior,  middle  and 
inferior  hemorrhoidal.  The  superior  veins  which  are  alone 
implicated  in  the  formation  of  internal  hemorrhoids,  are 
tributaries  of  the  inferior  mesenteric,  while  the  middle  and 
inferior  veins  are  alone  implicated  in  the  formation  of  exter- 
nal hemorrhoids,  are  tributaries  of  the  internal  iliac.  There 
is  free  anastomosis  between  the  internal  and  external  venous 
systems,  being  known  as  the  hemorrhoidal  plexus.  The 
inferior  mesenteric  forms  part  of  the  vena  portae  and  the 
blood  is  thus  circulated  through  the  liver.  This  illustrates 
the  connection  with  internal  hemorrhoids  and  interference 
with  the  portal  circulation,  as  any  obstruction  in  the  latter 


RECTUM   AND  ANUS.  1 5 

would  necessarily  be  responsible  for  greater  pressure  in 
the  hemorrhoidal  veins.  This  is  illustrated  in  the  common 
occurrence  of  persons  experiencing  more  inconvenience  from 
their  piles  when  bilious.  As  the  external  venous  system 
empties  into  the  internal  iliac,  the  interruption  or  obstruc- 
tion of  the  portal  system  does  not  influence  external  piles, 
except  to  such  an  extent  as  may  be  due  to  the  anastomosis 
between  the  two  systems,  as  this  blood  passes  through  the 
common  iliacs  and  inferior  vena  cava  to  the  heart. 

Internal  piles  are  covered  by  mucous  membrane  only, 
which  is  usually  thickened  and  changed  in  color  and  con- 
sistence, according  to  the  length  of  time  they  have  existed, 
and  the  variety  to  which  they  belong. 

Those  of  Venous  origin  are  by  far  the  most  common. 
They  may  assume  almost  any  shape  and  size  and  are  bluish 
in  appearance  unless  when  strangulated,  when  they  may 
assume  a  purplish  hue.  These  tumors  may  be  small,  round, 
soft,  spongy  and  smooth  or  may  take  the  form  of  a  large 
corrugated  mass  filling'  the  entire  lower  portion  of  the  rec- 
tum. They  are  not  painful  unless  when  inflamed  and  stran- 
gulated, do  not  bleed  easily,  but  when  existing  in  large 
numbers  or  when  a  number  have  coalesced,  a  movement  of 
the  bowels  may  cause  quite  profuse  hemorrhage. 

Hemorrhoids  of  Capillary  origin  are  usually  of  a  dark 
color,  are  smaller  than  the  venous,  more  delicate,  bleed  easily 
when  touched  by  a  probe  and  are  not  painful.  They  seldom 
protrude  unless  when  accompanied  by  large  tumors. 

Arterial  hemorrhoids  are  bright  red  in  appearance,  very 
irritable,  bleed  freely,  are  of  delicate  structure  when  they 
first  make  their  appearance  and  are  subject  to  prolapse. 

External  piles.  The  varicose  form  of  external  piles 
is  a  varicosed  condition  of  the  external  hemorrhoidal  veins, 
with  or  without  infiltration  and  thickening  of  the  surround- 
ing tissue.  It  is  usually  of  a  bluish  or  purplish  tint,  smooth 
or  corrugated,  even  or  irregular.  The  thrombic  pile  is  due 
to  a  thrombus  in  the  external  hemorrhoidal  veins,  is  hard 
and  tense,  painful  and  liable  to  inflammation.     The  throm- 


1 6  DISEASES  OF  THE 

bus  may  be  absorbed  and  the  tumor  disappear  or  it  may 
develop  into  a  cutaneous  tab,  mentioned  under  that  variety. 

Of  the  cutaneous  variety  the  redundant  form  is  com- 
mon in  those  having  internal  piles  and  are  often  caused  by 
a  weakening  of  the  sphincter,  allowing  the  anal  edges  to 
prolapse. 

The  hyperplastic  form  is  due  to  hyperplasia  of  the  con- 
nective tissue  from  abrasions,  fissure  or  ulceration. 

The  hypertrophic  form  is  a  hypertrophy  of  the  normal 
radiating  folds  of  the  anus,  the  result  of  an  eczematous 
inflammation  or  the  remnant  of  one  of  the  forms  of  venous 
piles  that  has  undergone  spontaneous  cure. 

Rectal  Examinations  and  Treatment. 

As  a  rule,  all  persons  with  rectal  trouble  imagine  they 
have  piles,  and  the  majority  of  physicians  accept  the  patient's 
diagnosis  of  the  ailment  without  an  examination.  A  palli- 
ative ointment  is  prescribed  and  the  patient  receiving  no  ben- 
efit, consults  the  first  itinerant  "pile  doctor"  that  comes 
within  reach  and  is  promptly  cured.  At  the  next  meeting 
of  the  medical  society  the  question  of  how  to  eliminate  the 
quack  will  be  discussed,  but  no  definite  conclusion  will  be 
reached. 

When  a  person  with  rectal  disease  consults  the  physi- 
cian, he  should  be  allowed  to  give  his  own  account  of  the 
trouble  as  he  understands  it,  after  which  the  physician  will 
proceed  to  make  inquiries  regarding  points  not  mentioned 
by  the  patient.  The  principle  points  to  be  determined  are, 
the  length  of  time  the  disease  has  existed,  whether  there  is 
pain  or  itching,  discharge  of  blood,  feces  or  mucus,  condi- 
tion of  the  bowels,  whether  there  is  protrusion  at  one  or  both 
sides  of  the  anus  during  the  act  of  defecation  and  whether 
the  protrusion  can  be  replaced  with  or  without  difficulty. 

If  from  the  outline  given  by  the  patient  there  is  reason 
to  suspect  the  presence  of  hemorrhoids,  or  other  rectal  dis- 


RECTUM   AND  ANUS.  1/ 

ease,  an  examination  should  be  made.  This  will  but  seldom 
be  objected  to  by  male  patients,  but  females  sometimes 
seriously  object.  To  such  it  is  by  far  the  better  plan  to  say, 
"Unless  you  will  permit  an  examination  to  be  made,  I  must 
refuse  to  accept  your  case  for  treatment.  Unless  I  can  treat 
you  intelligently  and  correctly,  I  prefer  not  to  treat  you  at 
all.  A  failure  to  effect  a  cure  in  your  case  would  incur  a 
useless  expense  on  your  part  and  compromise  my  profes- 
sional reputation,"  or  something  along  that  line.  Such  a 
statement  will  at  once  convince  the  patient  that  you  are  con- 
scientious and  do  not  wish  to  treat  her  simply  in  order  to 
obtain  the  fee  that  would  result,  and  but  rarely  fails  to  cause 
her  objections  to  be  laid  aside.  Occasionally  a  female  patient 
will  wish  time  to  consider  so  grave  a  matter  as  to  submit  to 
an  ocular  examination,  and  if  so  she  should  not  be  inter- 
fered with.  In  the  large  majority  of  cases  she  will  return 
before  you  expect  her. 

The  digital  examination  is  at  best  but  a  poor  excuse 
for  the  ocular.  After  much  experience  the  touch  can  be 
educated  to  distinguish  piles  from  polypi  and  ulcers  from 
catarrh  of  the  rectum,  but  to  the  beginner  in  this  work, 
nothing  short  of  an  ocular  examination  should  be  counte- 
nanced. It  will  be  far  better  to  begin  the  treatment  of  this 
class  of  diseases  with  perfect  cures  in  a  few  cases,  than  many 
imperfect  ones. 

For  the  purpose  of  making  thorough  examinations,  a 
table  thirty-four  to  thirty-six  inches  high  is  preferable  to  a 
surgical  chair,  the  latter  being  too  low  for  comfortable 
work.  The  top  should  be  padded  or  covered  with  blankets. 
Fully  as  important  as  the  table  may  be,  none  the  less  so  is  a 
good  light. 

No  artificial  light  equals  that  of  the  sun  radiated  through 
a  frosted  glass  or  a  clear  pane  shaded  by  a  thin  white  curtain. 
In  cities  and  towns  where  gas  can  be  obtained  an  excellent 
light  can  be  secured  by  means  of  the  incandescent  mantles 
now  so  generally  used.  In  the  country  where  gas  or  electric 
lights  are  not  in  use  a  light  in  every  particular  as  bright 


lb  DISEASES  OF  THE 

can  be  obtained  from  gasoline,  consumed  in  a  mantle  of 
similar  construction  as  those  used  for  the  regular  illuminat- 
ing gas. 

An  ordinary  reflector  properly  located  will  aid 
materially  in  concentrating  the  light.  The  small  pocket 
electric  light  is  a  neat  and  convenient  affair  and  can  be  used 
to  great  advantage  in  rectal  examinations.  If  the  patient  has 
stated  that  protrusion  occurs,  he  should  be  directed  to  go  to 
the  closet  and  make  an  effort  to  strain  it  down.  If  unsuc- 
cessful, a  sufficient  quantity  of  water  should  be  thrown  into 
the  rectum  to  produce  an  action,  or  the  usual  time  at  which 
the  patient's  bowels  move  may  be  selected  for  the  examina- 
tion. The  advantage  of  this  procedure  is  that  if  the  trouble 
is  prolapse  of  the  rectum  it  can  at  once  be  determined,  and 
if  piles,  their  location  can  easily  be  ascertained  and  noted 
for  future  reference.  For  examination  the  patient  is  placed 
on  one  side,  the  knees  drawn  up  or  extended  on  a  wing 
attached  to  the  lower  end  of  the  table.  A  general  view  of  the 
anus  is  taken  and  any  abnormalities  noted.  Before  an 
internal  examination  is  made,  the  protrusion  must  be 
returned  and  the  parts  well  oiled  for  the  introduction  of  the 
speculum.  If  an  injection  of  water  was  not  given  for  the 
purpose  of  causing  a  protrusion,  it  is  well  to  do  this  as  it 
will  wash  away  the  mucus  and  retained  feces.  This  is  also 
a  good  plan  when  a  disease  other  than  piles  exists  when  there 
is  no  protrusion,  except  when  ulcer  is  suspected,  as  in  the 
latter  case  the  presence  and  location  of  mucus  is  of  diagnos- 
tic value.  While  some  writers  advocate  the  examination  and 
treatment  of  hemorrhoids  without  the  use  of  the  speculum, 
no  good  reasons  for  this  method  exist.  The  use  of  the 
speculum  is  not  difficult  nor  painful  to  the  patient,  and  its 
aid  cannot  be  over-estimated. 

In  the  selection  of  the  speculum  considerable  judgment 
should  be  exercised.  The  ordinary  bi-valve  speculum  is  not 
as  satisfactory  as  several  others  in  the  market.  Whatever 
else  may  be  said  of  the  methods  of  Brinkerhoff,  it  is  beyond 
all  doubt  true  that  he  devised  the  best  speculum  that  exists 


RECTUM    AND   A  XLS. 


19 


0618a 

No.  3  Brinkerhoff 's 
Rectal  Speculum,  length 
5  inches,  outside  diameter 
l'A  inch. 


to-day.  One  of  its  best  features  is  the  reflecting  end,  inclined 
inward,  which  reflects  a  splendid  light  on  the  rectal  mem- 
brane as  the  slide  is  withdrawn.  The  accompanying  cut  will 
illustrate  its  appearance  and  design.     Next  to  the  Brinker- 


20  DISEASES    OF    THE 

hoff  speculum,  the  O'Neil  is  probably  the  best,  and  indeed  it 
has  features  superior  to  the  former,  the  principal  one  being 
the  expansion  of  the  distal  end  of  the  speculum  in  the  rectum. 
Its  reflecting  powers  are  not  quite  as  good  as  those  of  the 
Brinkerhoff,  but  it  enables  a  larger  view  of  the  rectum  being 
taken  at  one  introduction.  Xo  speculum  with  which  I  am 
acquainted  is  superior  to  either  of  these.  Several  sizes  should 
be  carried,  a  small  and  medium  size  beincr  the  most  used. 


THE   O'NEIL   SPECULUM. 

Wittt  a  small  and  medium  size  Brinkerhoff  and  a  medium 
size  O'Neil,  all  work  can  be  done.  The  patient  being  placed 
in  a  position  so  that  the  light  will  be  thrown  into  the  rectum. 
the  speculum  is  oiled  and  introduced.  Olive  oil  is  usually 
recommended  for  this  purpose,  but  its  smell  is  so  disagree- 
able after  a  short  exposure  to  the  air  that  it  is  better  to  use 
one  of  the  hydro-carbon  oils,  liquid  petrolatum  or  vaseline. 
A  small  quantity  of  oil  is  also  introduced  just  within  the 
rectum.  Introduce  the  speculum  slowly,  giving  the  muscles 
time  to  relax,  bearing  in  mind  that  all  movements  about  the 
rectum  must  be  easy  and  gentle  to  prevent  spasmodic  con- 
traction of  the  sphincter.  Never  use  a  cold  speculum.  After 
the  instrument  has  been  introduced  its  entire  length,  the 
<=lide  is  gradually  withdrawn  and  an  inspection  made  of  the 


RECTUM   AND  AX  US.  21 

membrane  protruding  through  the  opening.  When  the  slide 
is  withdrawn  no  effort  should  be  made  to  return  it,  but  the 
speculum  must  be  withdrawn  and  the  slide  then  replaced  and 
again  introduced,  turning  the  speculum  slightly  so  as  to 
expose  another  portion  of  the  bowel.  From  three  to  four 
introductions  are  required  to  view  the  entire  interior  of  the 
rectum.  The  patient  should  be  instructed  to  bear  down 
occasionally  during  the  examination  so  as  to  distend  the 
parts  and  fill  up  the  capillaries  or  veins.  The  examination 
having  revealed  the  condition  of  affairs,  treatment  will  be 
instituted  accordingly,  as  hereafter  detailed. 

In  the  light  of  our  present  positive  knowledge,  begotten 
by  personal  and  the  accumulated  experience  of  many  special- 
ists, it  is  not  presumptive  to  make  the  statement  that  in  anv 
and  every  case  of  true  hemorrhoids,  a  cure  can  be  effected 
without  in  the  least  endangering  the  life  of  the  patient  or 
without  the  resort  to  a  painful  surgical  operation. 

The  popular  dread  of  surgical  operations  is  well  known, 
and  indeed  there  are  sufficient  reasons  for  it,  and  any  other 
means  by  which  we  can  safely  obtain  the  same  end  is 
appreciated  and  gratefully  accepted  by  the  general  public. 
Persons  afflicted  with  hemorrhoids  will  readily  submit  to  the 
injection  treatment  if  assured  that  the  treatment  is  safe, 
practically  painless  and  curative.  This  we  can  guarantee. 
The  advocates  of  the  injection  method  are  divided  on  the 
subject  of  the  advisability  of  injecting  External  piles, 
although  the  treatment  is  recommended  by  no  less  an 
authority  than  Agnew,  but  condemned  by  the  majority  of 
others.  The  injection  of  the  external  venous  pile  is  with- 
out doubt  admissible,  but  this  treatment  in  the  cutaneous 
form,  for  the  removal  of  the  skinny  tabs,  is  useless.  More 
will  be  said  of  this  under  the  treatment  of  external  piles. 
For  internal  piles  of  all  varieties,  the  injection  treatment  is 
universally  applicable.  The  diagnosis  of  the  different 
varieties,  while  desirable  from  a  technical  point  of  view,  is  of 
little  or  no  advantage  when  it  comes  to  treatment.  A  suffi- 
cient classification  as  far  as  pertains  to  the  treatment  is  that 


22  DISEASES   OF    THE 

.which  differentiates  the  internal  from  the  external,  and  the 
.venous  from  the  cutaneous  external  piles. 

Patients  will  frequently  consult  a  physician  in  regard  to 
hemorrhoids  when  they  are  in  a  state  of  strangulation  or 
inflammation,  after  several  days  of  unsuccessful  attempts  to 
relieve  this  condition.  If  the  ordinary  efforts  at  reduction 
fail,  place  the  patient  in  the  knee-chest  position,  allowing  the 
intestines  to  gravitate  toward  the  chest.  The  protruded  and 
inflamed  mass  is  now  covered  with  a  pledget  of  cotton  wet 
with  a  10%  solution  of  cocaine  which  is  held  in  place  for 
a  few  minutes.  Vaseline  is  now  applied  to  the  piles  and 
one  finger  inserted  into  the  rectum.  With  the  other  hand 
gently  press  on  each  tumor  in  succession  and  empty  them  of 
their  blood,  returning  them  into  the  rectum  as  rapidly  as 
emptied.  If  this  method  is  not  successful  hot  water  injec- 
tions may  be  given  and  the  process  repeated.  The  cases 
that  resist  this  method  of  reduction  are  very  rare.  The 
injection  treatment  must  never  be  employed  when  piles  are 
in  a  state  of  inflammation,  but  palliative  measures  must  be 
instituted  to  reduce  the  congestion.  For  this  purpose  hot 
douches,  hot  sitz  baths,  soothing  ointments,  such  as  are  here- 
after mentioned,  or  injections  of  distilled  extract  of  witch 
hazel  are  employed.  When  piles  are  very  large,  a  similar 
preparatory  treatment  will  lessen  the  tendency  to  local  con- 
gestion after  treatment.  The  patient  should  have  the  bowels 
evacuated  before  the  treatment,  so  that  no  movement  will 
occur  for  a  day  or  two  afterward.  A  laxative  of  cascara 
sagrada,  senna,  or  other  gentle  aperients  may  be  employed. 
If  there  is  but  little  tendency  to  constipation,  laxatives  are 
not  necessary,  as  an  easy  movement  does  not  interfere  with 
the  injected  piles.  The  injections  are  made  with  the  ordinary 
hypodermatic  syringe  with  a  set  screw  on  the  piston  by  which 
the  amount  injected  can  be  regulated.  The  needle  should  be 
three  or  four  inches  long,  gold  pointed  preferred,  and 
supplied  with  a  sheath  by  which  the  point  can  be  exposed 
sufficiently  to  enter  the  pile  and  not  pass  through  it.  A 
difference  of  opinion  exists  between  practitioners  using  the 


RECTUM    AND  ANUS.  2$ 

injection  method  for  treating  piles  as  to  whether  injections 
should  be  made  into  them  while  protruded,  without  the  use 
of  the  speculum,  or  using  the  speculum,  inject  them  inside 
of  the  rectum.  Each  method  has  its  advocates  whose  claims 
are  well  supported,  but  in  so  far  as  my  experience  teaches, 
the  internal  method  is  to  be  preferred. 

Carbolic  acid,  in  various  strengths  and  different  com- 
binations, has  been  proven  to  be  the  most  satisfactory  agent 
for  the  purpose  of  curing  piles  by  the  injection  method.  A 
common  error  in  preparing  solutions  for  this  purpose  is  that 
the  carbolic  acid  is  used  in  too  weak  a  solution.  Although 
prominent  and  successful  operators  employ  carbolic  acid  in 
ten  to  twenty  per  cent,  solution,  and  claim  to  cure  a  large 
percentage  of  cases,  it  has  been  demonstrated  beyond  ques- 
tion that  better  results  are  obtained  when  it  is  used  in  fifty 
or  more  per  cent,  solution. 

Dilute  carbolic  acid  is  painful,  is  not  cauterant,  and 
does  not  cause  sufficient  sloughing  to  remove  the  tumor. 
When  used  in  fifty  to  sixty-five  per  cent,  solution  its  action 
is  anesthetic  and  cauterant,  and  the  slough  produced  will  be 
sufficient  to  eradicate  the  tumor  entirely.  The  much  harped 
theory  of  a  clot  forming  and  passing  along  the  veins  to  the 
heart  is  not  possible  when  fifty  per  cent,  or  stronger  solution 
is  used,  as  such  a  fluid  at  once  coagulates  the  blood  and 
immediately  stops  the  circulation  in  the  part.  When  the 
object  of  all  injections  is  to  cause  coagulum  formation  and 
devitalization  of  the  parts,  so  that  a  slough  will  result,  it 
seems  poor  practice  to  inject  just  enough  to  cause  a  few 
clots  and  set  up  a  severe  inflammation.  The  occasional  bad 
results  that  are  reported  as  arguing  against  the  injection 
method,  would,  if  investigated,  be  found  to  have  been 
produced  by  using  one  of  these  weak  solutions  which  only 
tantalize  a  pile  tumor  and  often  incapacitate  the  patient. 
Carbolic  acid  in  weak  solutions  is  painful  and  dangerous,  and 
in  addition  to  the  local  effects,  may  be  absorbed  and  cause 
toxic  symptoms,  but  in  strong  solutions  it  is  non-absorbable. 


24  DISEASES  OF  THE 

promptly  coagulates  blood  and  serum,  acts  as  its  own  anes- 
thetic and  is  perfectly  safe. 

It  is  safe  to  say  that  one-half  of  the  medical  profession 
is  not  thoroughly  acquainted  with  this  feature  of  carbolic 
acid.  Fearing  to  use  carbolic  acid  in  a  strong  solution,  they 
employ  one  that  is  but  little  more  than  carbolized  water,  and 
by  so  doing  they  invite  the  very  effect  that  they  seek  to  avoid. 

In  this  connection  extracts  from  writers  on  this  point 
will  be  quoted  which  should  convince  any  physician  of  the 
absolutely  reliable  agent  we  have  in  carbolic  acid,  used  in 
strong  solution. 

Dr.  Agnew  says :  "I  have  always  maintained  that  there 
is  absolutely  no  danger  of  carbolic  acid  poisoning  from  the 
local  use  of  strong  solutions,  and  I  am  borne  out  in  my  belief 
both  by  reason  and  experience.  In  strength  of  fifty  per  cent. 
up,  carbolic  acid  will  cauterize  the  tissue  of  hemorrhoids  as 
effectually  as  the  hot  iron,  and  will  strangulate  the  circulation 
at  once.  It  coagulates  albumen  instantly  and  spends  its  force 
and  exhausts  itself  right  there  and  then,  leaving  none  to  be 
absorbed.  Strong  solutions  also  guard  against  embolism 
by  forming  a  tough,  compact  and  insoluble  coagulum ;  the 
coagulum  being  strengthened  and  its  component  parts  closely 
bound  together  into  one  solid,  conglomerate  mass  by  the 
fibrous  tissue  forming  the  network  of  a  hemorrhoidal  tumor. 
A  weak,  thin  watery  solution,  aside  from  doing  poor  work, 
is  much  more  liable  to  diffuse  itself  and  be  carried  into  the 
circulation  like  a  hypodermic  of  morphia,  than  a  solution 
sufficiently  strong  to  act  as  a  cauterant,  by  which  the  tissue 
is  destroyed,  a  tough,  compact  and  an  insoluble  coagulum  is 
formed,  and  the  circulation  strangulated  at  once." 

Dr.  Dorland,  of  Chicago,  says:  "When  a  compact 
coagulum  is  formed  and  the  muscular  structure  of  the  bowel 
is  not  touched  by  the  styptic,  it  is  impossible  to  do  harm,  all 
the  learned  theory  to  the  contrary  notwithstanding.  A  weak 
solution  forms  little  globules  in  a  tumor  and  we  can  imagine 
one  so  small  as  to  be  carried  into  the  circulation." 

Dr.  Havnes  of  Los  Angeles,  Cal.,  treated  fifteen  cases 


RECTUM   AND  ANUS.  2$ 

of  hemorrhoids,  ranging  from  a  mild  to  a  severe  type,  with 
weak  solutions  of  carbolic  acid,  with  anything  but  satisfac- 
tory results.  Five  cases  were  treated  with  five  minim 
injections  of  a  two  per  cent,  solution  at  intervals  of  ten  days. 
The  pain  was  intolerable  and  crural  phlebitis  occurred  in  one 
case  which  confined  the  patient  two  months.  In  the  remain- 
ing ten  cases  five  minims  of  a  five  per  cent,  solution  were 
employed  with  better  satisfaction,  but  there  was  more  or 
less  pain  and  partial  failure  to  cure.  The  fifteenth  case  was 
treated  thus  until  but  two  small  but  annoying  tumors 
remained.  These  were  constricted  at  their  base  by  the  wire 
of  a  nasal  snare,  and  pure  carbolic  acid,  crystals  liquefied  by 
heat,  was  injected  into  each  tumor  until  each  turned  white. 
He  announced  as  the  result  of  this  treatment  that  the  case 
was  cured  with  but  slight  inconvenience,  and  that  two  other 
cases  similarly  treated  were  equally  satisfactory. 

Dr.  Hoyt  of  New  York,  says :  "There  is  not  a  hemor- 
rhoidal case  possible  which  cannot  be  obliterated  by  this 
means,  and  I  am  at  a  loss  to  explain  why  so  many  cling  to 
methods  that  carry  so  much  havoc  and  suffering.  If  every 
college  in  the  land  would  have  this  subject  demonstrated  by 
men  of  experience  and  learning,  all  other  methods  would 
soon  lose  recognition." 

Dr.  Howard  Crutcher,  of  Chicago,  has  treated  eight 
hemorrhoidal  tumors  at  one  time,  using  one  hundred  and 
sixty  drops  of  pure  carbolic  acid,  with  the  results  of  total 
obliteration  of  the  tumors  without  the  slightest  unfavorable 
symptom. 

The  complete  strangulation  of  the  circulation  renders 
inflammation  of  the  tumor  impossible,  as  inflammation  can- 
not occur  in  tissue  where  there  is  no  circulation,  and  the 
solidity  of  the  coagulum  renders  the  liability  to  embolism 
exceedingly  remote.  Accidents  and  complications  may 
occasionally  occur,  but  these  occur  in  the  practice  of  every 
physician,  no  matter  what  method  he  employs.  Used  intelli- 
gently and  properly,  carbolic  acid  injections  will  cure  more 
cases  of  hemorrhoids  with  less  inconvenience  to  the  patient. 


26  DISEASES   OF   THE 

than  any  other  method  with  which  we  are  at  present 
acquainted. 

Dr.  Hoyt  of  New  York,  in  a  recently  published  article 
sums  up  the  comparative  advantages  of  this  method  as 
follows : 

"A  large  number  of  persons  adopt  these  ideas  that 
would  never  subject  themselves  to  other  methods. 

"As  the  surface  of  a  hemorrhoidal  tumor  is  never 
broken,  there  is  no  such  thing  as  post-operative  hemorrhage. 

"A  skillful  application  of  this  system  leaves  pain  out 
of  the  experience  of  patients  and  they  can  attend  to  their 
usual  affairs. 

"A  case  thoroughly  restored  is  permanent;  but  if  it  had 
to  be  treated  every  year,  the  advantages  would  still  exist. 

"Any  substance  injected  into  animal  tissue  travels  in 
the  direction  of  the  least  resistance;  hence  in  these  matters 
it  does  not  invade  deeper  relations  to  their  detriment. 

"The  general  health  improves  from  the  first  day,  and 
so  the  patient  is  not  sick  a  long  time  after  he  gets  well. 

"The  greatest  advantage  of  this  interstitial  invasion,  as  a 
means  of  destroying  hemorrhoids,  is  that  there  are  no  dis- 
advantages." 

Hemorrhoidal  Ixjection  Fluids. 

As  formulae  for  the  injection  of  hemorrhoids  the  follow- 
ing are  rational  in  composition  and  satisfactory  in  action. 
Other  popular  combinations  are  mentioned  at  the  close  of  this 
chapter. 

The  following  combination  is  the  one  I  most  frequently 
employ.  It  fills  every  requirement  and  will  produce  results 
that  cannot  be  excelled  by  any  other  formulae,  for  the  simple 
reason  that  it  obliterates  the  hemorrhoids  effectively  with 
as  little  disturbance  as  is  possible  with  any  other.  I  have 
used  other  combinations  which  are  just  as  good,  Agnew's 
for  instance,  yet  I  see  no  reason  why  I  should  prefer  it  to 
this  one. 


RECTUM    AXD   A  XL'S.  2/ 

If      Carbolic   Acid — Pure fl.  5  ij-iij. 

Purified  Sperm  Oil fl.  5  ij. 

Mix.  Sig.  Inject  sufficient  into  each  tumor  to  change 
its  appearance  to  grayish  or  white. 

The  quantity  required  depends  entirely  upon  the  size  of 
the  tumor.  In  small  tumors,  where  three  minims  only  are 
required,  the  stronger  solution  may  be  used,  while  in  large 
tumors,  where  sometimes  two  to  four  drachms  are  required, 
the  fifty  per  cent,  solution  may  be  used.  This  formula  is 
equal  to  the  best. 

When  carbolic  acid  is  mentioned,  I  refer  to  the  pure 
crystalized  article,  which  for  the  purpose  of  forming  solu- 
tions is  liquefied  by  heat,  without  the  addition  of  either  water 
or  glycerine.  I  formerly  used  Calvert's  acid,  but  I  have 
since  learned  that  the  American  chemist  can  produce  an 
acid  in  every  particular  the  equal  of  the  English  product,  and 
at  a  cost  almost  seventy-five  per  cent.  less.  I  use  either 
Merck's  dry  crystals  or  Mallinckrodt's  best  grade  acid. 

Olive  oil,  sweet  almond  oil  or  glycerine  may  be  used  as 
a  diluent,  but  the  sperm  oil  is  I  think  preferable  to  a 
vegetable  oil.  Glycerine  is  not  so  desirable  on  account  of 
its  hygroscopic  character.  There  is  apparently  more  liability 
to  pain  and  tenderness  when  glycerine  is  used,  due  probably 
to  a  certain  degree  of  engorgement  caused  by  its  attraction 
of  moisture  from  the  surrounding  parts.  The  glycerine  is 
also  not  absorbed  as  readily  as  the  oils  and  thereby  produces 
a  larger  sloughing  area. 

The  liquid  petrolatums,  vaselines  and  the  other  hydro- 
carbon oils  are  not  miscible  with  carbolic  acid. 

Dr.  Agnew's  solution  is  one  which  produces  very  satis- 
factory results.  It  combines  with  carbolic  acid,  acetate  of 
lead,  borax  and  glycerine.  The  coagulating  action  of  the 
acid  is  undoubtedly  augmented  by  the  addition  of  the  acetate 
of  lead.     The  formulae  for  making  this  fluid  are : 


28  DISEASES   OF    THE 

^     Acetate  of  Lead, 

Biborate  of  Soda aa  o  ij. 

Glycerine,  Price's fl.  §  j. 

Mix  in  a  graduate  and  pour  into  a  two  ounce  vial,  and 
let  stand  for  twenty-four  hours.  The  solution  of  the  salts 
is  hastened  by  placing  the  vial  in  a  warm  water  bath  and 
letting  it  remain  there  for  fifteen  or  twenty  minutes.  The 
glycerine  can  be  better  handled  and  its  measurements  more 
accurately  made  by  warming  it  and  also  the  graduate. 

This  solution  having  been  made,  the  fluid  can  be  com- 
pounded. 

I£     Acid  Carbolic,  liq.  cryst fl.  5  j. 

Distilled  Water fl.  0  ij. 

Glycerite  of  Lead  and  Borax fl.  3  vj. 

Mix.    Sig.     Solution  for  hemorrhoids. 

The  object  of  the  water  in  the  formula  is  to  lessen  the 
syrupy  consistence  of  the  fluid.  Without  the  water  it  is 
rather  heavy  for  hypodermatic  injection,  as  it  does  not  pass 
through  the  needles  freely.  Dr.  Agnew  says  of  this  com- 
bination :  "The  addition  of  the  acetate  of  lead  is  designed  to 
restrict  the  action,  and  that  of  the  borax  to  lessen  the  irri- 
tating properties  of  the  acid.  The  acetate  of  lead  not  only 
keeps  within  limits  the  distribution  of  the  acid  at  the  time 
the  solution  is  forced  out  of  the  syringe,  but  of  itself  com- 
bines with  a  certain  portion  of  the  albumen  of  the  blood  and 
tissues,  forming  the  albuminate  of  lead."  He  further  says 
that  he  has  experimented  with  carbolic  acid  in  different 
strengths  and  if  he  were  to  change  his  formula  it  would  be 
toward  an  increase,  rather  than  a  diminution  of  the  quantity 
of  the  acid.  This  fluid  also  turns  pile  tumors  grayish  or 
white,  and  must  be  used  in  sufficient  quantity  to  produce  this 
change.  Piles  of  a  delicate  texture  and  covering,  undergo 
change  of  color  more  quickly  and  to  a  greater  degree  than 
those  more  fibrous  and  tousrher  in  character.  -  •  - 


RECTUM   AND  ANUS.  29 


INJECTING  THE  FLUID. 

After  an  examination  has  been  made  and  the  location  of 
the  piles  discovered,  the  patient  should  lie  on  the  side 
opposite  to  that  to  which  the  piles  are  attached,  and  the 
speculum  introduced  so  that  the  tumor  will  protrude  down- 
ward through  the  fenestrum  when  the  slide  is  withdrawn. 
(The  Brinkerhoff  speculum  is  referred  to.)  In  this  position 
the  fluid  injected  will  gravitate  toward  the  apex  of  the  now 
pendant  pile,  and  will  not  so  easily  permeate  the  structures 
underlying  its  base,  neither  will  any  damage  be.  done  by 
overflow  of  the  fluid  on  the  mucous  membrane,  as  in  case 
of  an  overflow  it  will  be  caught  in  the  speculum.  An  over- 
flow will  not  occur  when  the  injection  is  properly  made  and 
the  needle  not  withdrawn  too  quickly.  After  the  tumor  has 
been  exposed,  ask  the  patient  to  bear  down  and  introduce  the 
needle  with  a  quick  thrust.  There  is  in  many  cases  no  pain 
whatever  connected  with  the  introduction  of  the  needle, 
patients  frequently  not  knowing  that  the  needle  has  been 
inserted,  and  the  use  of  cocaine  before  injecting  is  entirely 
unnecessary.  The  needle  should  be  inserted  about  midway 
between  the  apex  and  the  middle  of  the  tumor  and  the  fluid 
injected  a  minim  at  a  time,  watching  for  the  change  of  color 
before  mentioned.  Large  tumors  cannot  be  thoroughly 
injected  by  one  insertion  of  the  needle,  on  account  of  the 
coagulum  formation  about  the  needle,  and  as  many  more 
injections  must  be  made  as  are  required  to  permeate  the 
entire  tumor. 

Keep  the  needle  in  place  for  a  few  minutes  after  suffi- 
cient fluid  has  been  injected,  and  withdraw  carefully.  If 
blood  follows  its  withdrawal,  enough  fluid  has  not  been 
injected  and  the  needle  should  be  re-inserted  and  more 
injected.  Large  tumors  are  frequently  divided  into  separate 
cavities,  probably  through  anastomosis  of  veins,  and  in  these 
cases  the  entire  tumor  cannot  be  permeated  by  one  injection. 


3©  DISEASES  0E  THE 

The  injection  of  the  fluid  is  attended  with  but  little  pain, 
and  is  only  momentary.  If  a  great  deal  of  pain  is  com- 
plained of,  the  deeper  tissues  are  probably  being  invaded. 
The  powerful  anesthetic  action  of  carbolic  acid  compounds 
of  this  strength  quickly  deaden  all  sensibility.  After  the 
needle  has  been  removed,  the  tumor  may  be  smeared  with 
vaseline  and  the  speculum  removed.  The  pain  which  some- 
times follows  an  injection,  will  appear  within  four  hours,  if 
it  appears  at  all.  Persons  with  piles  usually  do  not  seek 
relief  until  they  have  suffered  the  most  excruciating  pain, 
consequently  a  little  pain,  such  as  sometimes  follows  injec- 
tion, is  usually  not  complained  of,  except  in  nervous  or 
irritable  persons  whose  slightest  discomfort  causes  consider- 
able disturbance.  To  such,  an  opium  suppository  may  be 
given  for  use  if  required,  and  hot  sitz  baths  ordered,  or  if 
severe,  it  may  be  controlled  by  morphine.  Sympathetic 
paralysis  of  the  bladder  or  stricture  of  the  urethra  some- 
times occurs,  rarely  however,  and  is  only  temporary.  It 
may  be  relieved  by  hot  baths,  hot  applications  to  the  bladder 
and  perineum  or  by  the  catheter.  It  will  subside  with  that 
of  the  inflammation  of  the  rectum.  For  retention  of  urine, 
when  the  catheter  cannot  be  passed  on  account  of  the  spasm 
of  the  urethra,  give  one-third  grain  of  pilocarpine  every 
half  hour,  until  complete  relaxation  takes  place  and  free 
diaphoresis  has  been  established,  or  pass  the  Faradic  current 
through  the  bladder.  If  the  bowels  incline  toward  a  move- 
ment, while  the  first  inflammatory  effects  are  present,  inject 
slippery  elm  water  into  the  rectum,  hot,  so  as  to  make  the 
passage  easy.  Usually  however,  there  is  so  little  inflamma- 
tion that  no  attention  need  be  paid  to  the  action  of  the 
bowels,  particularly  as  an  evacuation  usually  precedes  the 
treatment,  to  which  reference  has  been  made.  In  cases  where 
the  tumors  injected  have  been  very  large,  the  patient  should 
refrain  from  active  exercise  for  a  few  days,  but  in  small  and 
medium  sized  tumors  this  injunction  need  not  be  given.  It 
is  best  not  to  inject  more  than  two  small  or  medium,  or  one 
large  sized  tumor  at  one  treatment,  and  ten  davs  to  two  weeks 


RECTUM   AND  ANUS.  3  I 

should  elapse  between  treatments.  Small  tumors  should  be 
treated  first  as  after  the  large  ones  have  been  removed,  the 
small  ones  are  difficult  to  locate.  Agnew  recommends  the 
treatment  of  a  number  of  tumors  at  one  treatment,  and  while 
it  may  be  safe  and  proper  practice,  there  are  several  reasons 
against  this  procedure.  Physicians  may  be  guided  as  their 
experience  dictates  in  this  matter. 

Ninety-five  per  cent,  of  cases  require  no  attention  what- 
ever after  the  treatment,  and  can  follow  their  usual  vocation. 
In  the  remainder,  minor  complications  may  occur,  some  of 
which  have  already  been  referred  to.  Secondary  hemor- 
rhage but  rarely  occurs,  and  can  usually  be  checked  by  the 
introduction  into  the  rectum,  against  the  bleeding  surface,  of 
several  pieces  of  ammonio-ferric  alum,  and  kept  in  place 
by  compression  obtained  by  plugging  the  rectum  with  cotton. 
The  other  usual  methods  of  controlling  hemorrhage,  the 
hemostatic  forceps,  the  ligature  or  torsion  may  be  employed. 

Extensive  ulceration  and  sloughing  will  not  occur  unless 
when  the  deeper  tissues  have  been  invaded  by  the  fluid. 
This  will  not  occur  if  the  injection  is  made  with  the  tumor 
in  a  pendant  position,  as  before  directed.  If  the  ulceration 
should  show  indisposition  to  heal,  the  usual  treatment  for 
ulceration  of  the  rectum  may  be  employed. 

The  complications  referred  to  will  only  occur  in  rare 
cases,  and  are  no  excuse  whatever  for  a  condemnation  of 
the  method.  If  all  other  treatments  were  safe,  the  objec- 
tions might  be  sustained,  but  the  contrary  being  more 
applicable  to  other  forms  of  treatment,  no  reasonable  argu- 
ments can  be  offered  against  the  adoption  of  this  eligible 
method  of  treating  hemorrhoids. 

Having  noticed  previously,  the  employment  of  weaker 
solutions  of  carbolic  acid  by  successful  specialists  in  this 
work,  a  few  formulae,  with  comments  by  their  advocates, 
will  follow.  While  not  for  a  moment,  questioning  the  state- 
ments of  these  men,  nor  wishing  to  detract  from  whatever 
influence  their  conclusions  may  have  upon  those  who  follow 
their  example,  I  cannot  but  endeavor  to  impress  the  thought 


2,2  DISEASES   OF  THE 

that  whatever  good  results  may  be  obtained  by  the  use  of 
carbolic  acid  in  weak  solutions,  they  are  but  a  foretaste  of 
the  brilliant  achievements  attainable  by  the  use  of  the  strong' 
solutions.  Advocates  of  weak  solutions,  less  than  thirty-five 
per  cent,  are  on  the  right  track,  although  somewhat  hampered 
by  their  views  in  this  matter,  but  I  have  infinitely  more 
admiration  for  them  than  for  the  hide-bound  individuals 
who  condemn  the  method  without  investigation  of  its  merits 
and  who  base  their  opinions  on  the  results  following  its 
application  by  the  ignorant  non-graduate  itinerant  "pile 
doctor,"  instead  of  those  attained  by  intelligent,  educated  and 
successful  practitioners.  While  the  bulk  of  the  profession  is 
condemning  the  treatment,  those  of  it  who  have  been  progres- 
sive enough  to  enter  upon  it,  will  continue  to  prosper.  "The 
harvest  is  plenty,  but  the  laborers  are  few." 

Dr.  Monroe,  of  Louisville,  uses 

I£     Carbolic  Acid,  pure fl.  3  j. 

Olive   Oil fl.  3  iij. 

Mix  by  putting  bottle  in  hot  water. 

Sig.  Inject  into  tumors  a  sufficient  quantity  to  turn 
them  white.  Several  days  before  operating,  he  advises  the 
use  of  calomel  and  soda  for  action  upon  the  liver.  This 
should  be  followed  by  one  or  two  seidlitz  powders.  One 
hour  before  operating,  the  patient  should  use  an  injection 
of  one  pint  of  warm  water  in  which  a  teaspoonful  of  boracic 
acid  has  been  dissolved. 


Dr.  R.  D.  Mason  of  Omaha,  uses  Carbolic  Acid  in 
50%  solution,  with  glycerine  and  water,  and  also  reports 
good  results  from  the  use  of  the  formula  of  Dr.  Agnew. 

He  recommends  the  following  formula  also,  but  to  com- 
pound it  properly,  some  skill  is  required. 


RECTUM   AND  ANUS. 


33 


I£      Napthaline    3  ij. 

Acid  Carbolic fl.  5  ij 

Hydrastine    Mur grs.  iij. 

Morphine  Sulph g-rs.  vj< 

Acid   Tannic errs.  xv. 

Fl.  Ext.  Ergot fl.  5  iv. 

Mix.     Dissolve  the  naphthaline  in  ether  before  mixing 
with  the  other  ingredients. 

Sig.     Inject  one  or  two  drops  into  each  tumor  at  first, 
and  gradually  increase  to  six  or  eight  drops  as  required. 

Dr.  Eliot,  of  Washington,  D.  C,  recommends  the  fol- 
lowing : 

R     Acid  Carbolic,  95% fl.  5  ij. 

Fid.  Ext.  Ergot fl.  3  ij. 

Mix.     Sig.    Inject  according  to  size  of  tumor. 

Dr.  Shuford's  Formula. 

I?      Sodium  Biborate 3  j 

Acid  Salicylic 3  j 

Acid    Carbolic fl.  5  ^j 

Glycerine .  fl    5  : 

Mix.  Sig.  Inject  three  to  five  drops  in  small,  and 
eight  to  ten  or  more  in  large  ones. 

Dr.  Shu  ford  claims  for  this  formula,  that  it  is  compara- 
tively painless,  causes  no  accidents  and  is  eminently  success- 
ful. The  hypertrophy  disappears  and  is  thrown  off,  leaving 
a  smooth,  healthy  mucous  surface. 


Overall's  Formula. 

I>     Acid  Carbolic, 

Glycerine, 

Fl.  Ext.  Ergot aa  p.  e. 

Mix.     Sig.  Inject  three  to  eight  drops. 


34  DISEASES   OF   THE 

Dr.  Hoyt  recommends, 

^     Acid  Carbolic n\  lxxx. 

Ext.  Hamamelis,  Distilled. 

Distilled  Water aa  fl.  5  vj. 

Mix.     Sig.     Inject  sufficient  to  produce  a  paleness  of 
the  surface  of  the  pile,  injecting  the  fluid  a  drop  at  a  time. 


Rorick's  Formula. 

I>      Acid  Carbolic fl.  3  ij. 

Glycerine fl.  3  ij. 

Fid.  Ext.  Ergot fl.  3  j. 

Distilled  water fl.  3  iss. 

Mix.     Sig.     Inject  from  two  to  ten  drops,  according 
to  size  of  tumor. 


The    following    is    given    by    Mason,    stating    that    he 
received  it  from  one  who  paid  fifty  dollars  for  it. 

IJ      Carbolic  Acid fl.  5  iv. 

Acetate  of  Lead 3  j. 

Salicylic    Acid gr.  xxx. 

Cocaine  Mur gr.  x. 

Aqua  Dest, 

Glycerine aa  q.  s.  ft.  fl.  §  j. 

Sig.    Use  in  same  manner  as  other  compounds. 


RECTUM    AND  ANUS.  35 


External   Hemorrhoids. 

This  variety  of  piles  is  not  difficult  to  recognize.  They 
appear  at  the  verge  of  the  anus,  either  as  a  dark  blue,  or 
purplish  venous  tumor,  or  as  a  cutaneous  excrescence  or 
skinny  tab.  Venous  piles  are  very  often  of  an  irritable  nature 
and  cause  the  patient  considerable  inconvenience.  They  are 
also  subject  to  inflammation.  They  vary  in  size  from  that 
of  a  pea,  to  that  of  an  olive,  and  may  number  from  one  to 
four  or  more.  The  cutaneous  excrescences  are  usually  the 
remnant  of  a  venous  tumor,  which  has  undergone  spon- 
taneous cure.  External  piles  are  a  frequent  source  of  con- 
siderable itching. 

In  regard  to  injecting  external  venous  piles,  a  difference 
of  opinion  still  exists.  At  best,  it  can  only  reasonably  apply 
to  the  treatment  of  recently  formed  venous  tumors,  as  they 
soon  become  fibrous  and  contain  a  clot.  Dr.  Agnew  advises 
the  injection  of  this  variety,  the  treatment  being  applied 
after  the  manner  of  treating  internal  piles.  Of  the  treat- 
ment he  says :  "Notwithstanding  the  small  amount  of  cut- 
ting required  in  the  removal  of  an  external  hemorrhoid  by 
excision,  there  are  some  who  are  decidedly  averse  to  being 
treated  by  any  plan  involving  the  use  of  the  knife  or  scissors. 
Patients  will  readily  submit  to  this  treatment,  although 
informed  that  a  longer  time  is  required  for  the  complete 
eradication  of  a  tumor  thus  treated,  and  that  more  pain  and 
inconvenience  may  be  experienced  from  the  effects  of  the 
operation  than  would  be  from  that  by  excision.  This  treat- 
ment has  the  disadvantage  that  it  does  not  instantly  remove 
the  tumor  as  does  excision,  but  has  the  advantage  of  being 
a  bloodless  operation."  Replying  to  objections  to  the  treat- 
ment given  by  Dr.  Matthews,  he  says,  "The  reasons  given 
by  Dr.  Matthews  for  his  disapproval  of  the  treatment  of 
external  hemorrhoids  by  injection,  are  concentrated  in  the 
statements  that  'the  inflammation  excited  would  be  great,  the 


36  DISEASES   OF  THE 

pain  intense  and  ulceration  might  possibly  follow."  These 
statements,  as  I  have  demonstrated  time  and  again,  are  cer- 
tainly not  borne  out  by  experience,  and  are  to  me,  therefore 
of  a  purely  chimerical  character.  I  have  never  seen  anything 
more  than  ordinary  swelling  follow  an  injection,  a  limited 
amount  of  controllable  pain,  and  a  rapid  healing  of  the 
broken  surface,  though  not  as  rapid  as  that  after  a  removal 
by  excision." 

After  injection  of  external  venous  hemorrhoids,  three 
or  four  days  are  required  for  the  removal  of  the  tumor,  and 
patients  thus  treated  should  be  directed  to  take  but  little 
exercise  until  the  coagulum  has  been  thrown  off.  The 
covering  of  external  hemorrhoids  is  more  dense  and  fibrous 
than  that  of  the  internal,  and  after  the  coagulum  separates 
it  is  sometimes  advisable  to  trim  off  the  ragged  edges  left, 
with  a  scissors.  If  the  injection  seems  more  painful  at  the 
first  contact  of  the  solution,  or  when  tumors  are  exceptionally 
tender,  the  skin  may  be  injected  with  a  10%  cocaine  solution, 
and  as  anesthesia  is  produced  the  interior  of  the  tumor  may 
be  reached  and  immediately  anesthetized.  Follow  this 
immediately  with  the  injection  of  the  hemorrhoidal  fluid  and 
no  fear  of  cocaine  absorption  need  be  felt,  as  the  carbolic 
acid  will  so  coagulate  the  contents  of  the  tumor  that  circula- 
tion is  impossible.  The  tumor  should  be  injected  thoroughly, 
following  same  directions  as  detailed  under  internal  treat- 
ment, although  the  speculum  need  not  be  used,  in  fact  it 
could  not  be  used.  The  summit  of  the  tumor  should  be 
slightly  opened  after  injection,  so  that  the  clot  will  have  an 
.easy  egress.  This  simple  procedure  will  prevent  much  of 
the  attending  discomfort. 

The  injection  of  hard  fibrous  masses,  or  cutaneous  tabs 
is  not  to  be  considered.  It  is  against  all  theory  of  this  treat- 
ment and  in  practice  condemns  itself.  Cutaneous  tabs  are 
usually  nothing  but  fibrous  tissue  and  skin,  contain  no  clot 
and  are  usually  not  troublesome.  Their  removal  should  be 
accomplished  by  clipping  them  off  with  a  scissors  after 
anesthesia  of  tin-  parts,  by  the  Schleich  infiltration  method. 


RECTUM   AND  AX  US.  37 

Thrombotic  tumors,  which  will  be  found  to  be  hard  and 
firm,  liable  to  inflammation  and  painful,  should  be  incised 
and  the  clot  removed.  This  operation  is  simple  and  under 
local  anesthesia,  painless. 

A  20%  solution  of  cocaine  is  applied  to  the  tumor  and 
held  in  place  for  ten  minutes.  This  will  deaden  external 
sensation  and  a  weaker  solution  can  then  be  injected,  or  the 
Schleich  method  may  be  employed  and  anesthesia  of  the 
skin  produced.  In  making-  these  injections,  care  must  be 
taken  to  make  them  into  the  skin,  and  not  into  the  tumor. 
After  skin  anesthesia  has  been  produced  the  solution  may  be 
thrown  in  the  sub-structure.  The  formula  of  the  Schleich 
solution  is  prepared  in  tablet  form  by  manufacturing'  chem- 
ists and  can  readily  be  obtained,  with  full  directions  for  use. 
After  anesthesia  is  complete,  with  a  sharp  knife  make  a  verti- 
cal incision  through  the  skin  and  turn  out  the  clot.  Syringe 
out  the  cavity  with  Hydrozone,*  which  thoroughly  cleanses 
the  cavity  and  stops  the  slight  hemorrhage  that  occurs.  Now 
apply  to  the  cavity,  with  a  camel's  hair  brush,  a  solution  of 
equal  parts  of  glycerine  and  carbolic  acid,  pack  with 
absorbent  cotton  and  apply  a  T  bandage.  After  forty-eight 
hours,  remove  the  dressing,  wash  cavity  again  with  Hydro- 
zone,  dust  with  boracic  acid  and  dress  as  before.  No  further 
attention  is  usually  required.  Preceding  a  bowel  move- 
ment, after  the  operation,  give  an  injection  of  elm  bark  water, 
to  insure  an  easy  passage.  For  the  relief  of  the  inflamma- 
tory symptoms  of  external  piles,  various  formulae  have 
been  devised.  Several  are  appended.  Also  a  formula  for  an 
excellent  application  to  internal  hemorrhoids  after  injection. 


*Marchand's  Hydrozone  is  the  strongest  solution  of  peroxide  of 
hydrogen  on  the  market,  being  of  30  vol.  strength.  Bottles  containing 
it  are  now  corked  with  an  Automatic  Safety  Valve  Stopper,  which  pre- 
vents bursting  of  bottles  and  the  annoying  popping  of  corks  when  bot- 
tles are  opened. 


38  DISEASES   OF    THE 

I£     Cocaine    Muriate gr.  xv. 

Ergotin gr.  be. 

Ichthyol    gr.  Ixv. 

Calomel    gr.  xlv. 

Vaseline, 

Lanoline    aa  5  iv. 

Mix.  Sig.  For  the  relief  of  inflamed  and  painful 
venous  tumors  or  tabs.  Apply  to  parts  on  muslin,  keeping 
in  place  with  bandage. 


H      Acid  Tannic gr.  xv. 

Bismuth  Sub.  Nit gr.  xxv. 

Acid  Carbolic   gtt.  xij. 

Morphine   Sulphate gr.  viij. 

Vaseline q.  s.  ad.  "%  j. 

Mix.  An  excellent  application  after  operation,  or  where 
astringent  or  anodyne  treatment  is  indicated.  Useful  as  a 
general  palliative. 


I£     Bismuth  Sub  Nit, 

Iodoform    aa  o  j. 

Powd.    Opium gr.  xij. 

Ext.    Belladonna gr.  iv. 

Ol.    Eucalyptus gtt.  vj 

Cacao  Butter q.  s. 

Ft.  Suppos.  Xo xij. 

The  oil  disguises  the  iodoform.  Recommended  by 
Agnew  for  controlling  pain  after  injection.  Useful  in  any 
internal  irritation  or  inflammation. 


RECTUM   AND  ANUS. 


39 


3^     Rosin, 

Chian  Turpentine, 

Mutton   Tallow aa  5  j. 

Myrtle  Wax 3  jj. 

Olive  Oil fl.  §  v. 

Mix.     Melt  together  and  stir  until  cold.     Useful  as  an 
application  to  ulcers  which  show  indisposition  to  heal. 


3^      Calomel    5  j. 

Powd.  Opium   5  ss. 

Carbonate  of  Lead 3  ij. 

Oxide  of  Zinc *  ij. 

Olive    Oil l  iv. 

Fresh  Lard,  without  salt 5  iv. 

Mix.     Triturate  in  mortar  until  thoroughly  mixed.     A 
useful  ointment  for  irritable  piles,  internal  or  external. 


T$     Acid    Gallic o-r.  xx. 

Charcoal 3  ], 

Ext.  Witch  Hazel o-r.  xxx. 

Ext.    Hemlock o-r.  xxx. 

Cacao  Butter q.  s. 

Ft.  Suppos.  No x. 

To  be  inserted  into  the  rectum  for  bleeding  piles,  either 
from  the  action  of  the  feces  or  the  constant  annoying  oozing 
of  blood. 


4-0  DISEASES  OF  THE 

All  of  these  formulae  aie  merely  palliative,  although  in 
some  mild  cases,  permanent  relief  seems  to  be  obtained.  The 
majority  of  these  are  not  piles  however,  but  merely  an 
eczematous  or  pruritic  condition,  diagnosed  as  piles  by  the 
patient,  and  not  investigated  by  the  physician. 

For  insertion  into  the  rectum  after  injection  of  piles,  if 
large,  and  there  is  reason  to  suspect  more  than  ordinary 
reaction,  the  following  may  be  applied  to  the  tumors  instead 
of  vaseline,  as  before  recommended. 

E     Bismuth  Sub  Nitrate gr.  lx. 

Ichthyol    gr.  xxx. 

Cacao  Butter   3  iv. 

Mix  by  melting  the  cacao  butter  and  stirring  the 
ichthyol  into  it,  and  triturate  the  bismuth  in  a  mortar  with 
the  mixture  and  add, 

R-     Acid   Carbolic o  ss. 

Simple  Cerate 5  iss. 

Benzoinated  Lard q.  s.  ad.  §  iv. 

Mix.  Sig.  Apply  before  removing  speculum,  or,  intro- 
duce by  means  of  a  suppositor. 


OINTMENT  SUPPOSITOR. 


RECTUM   AND  ANUS.  41 


Rectal  Ulcer. 

Ulceration  of  the  rectum  is  more  common  than  is 
usually  supposed.  It  is  a  frequent  cause  of  reflex  disturb- 
ances which  none  but  a  rectal  specialist  would  recognize. 
Ulcers  are  found  in  all  parts  of  the  rectum  but  more  com- 
monly in  the  lower  third.  It  may  exist  merely  as  a  slight 
solution  of  the  continuity  of  the  mucous  membrane  or  in 
any  stage  of  ulceration  between  that  and  a  deep-seated,  tissut 
destroying,  well  defined  ulcer. 

When  located  high  in  the  rectum,  its  presence  is  not 
noticed  by  the  patient  as  quickly  as  when  close  to  the 
sphincter,  where  the  nerve  supply  is  the  greatest.  The 
symptoms  of  rectal  ulcer  may  conveniently  be  divided  into 
Direct  and  Reflex.  The  direct  symptoms  are  moisture 
about  the  anus,  more  or  less  itching,  inflammation  and 
oedema  of  the  anal  tissues,  stools  streaked  with  blood  and 
mucus,  or  followed  by  a  discharge  of  a  scum  resembling 
boiled  starch,  desire  to  remain  long  at  stool,  tenesmus,  inflam- 
mation of  the  rectum,  a  sense  of  weight  and  a  dull  heaw 
feeling  in  the  lower  part  of  the  rectum. 

The  reflex  symptoms  are  numerous.  The  chief  of  these 
being  a  morning  diarrhoea.  There  is  usually  considerable 
flatus,  and  feces  pass  in  small  lumps  or  scybala.  The  desire 
for  stool  is  frequently  urgently  felt  immediately  on  rising  in 
the  morning,  and  subsides  after  several  attempts  to  evacuate 
the  bowels  have  been  made.  This  symptom  is  usually  not 
classed  as.  reflex,  but  its  presence  cannot  be  satisfactorily 
accounted  for  under  any  other  premises.  Patients  who  make 
the  statement  that  an  inclination  to  stool  is  felt  immediately 
after  a  cold  drink  or  certain  food  is  taken,  should  be  sus- 
pected of  having  rectal  ulcer.  Constipation  may  alternate 
with  diarrhoea,  but  the  latter  is  present  more  than  two-thirds 


4^  DISEASES   OF  THE 

of  the  time.  In  addition  to  these  symptoms,  there  may  be 
dizziness,  irritability  of  the  bladder,  eroticism,  emissions, 
hysteria,  nausea  or  vomiting,  pain  in  the  lumbar  region, 
sallow  complexion,  burning  of  the  soles  of  the  feet,  and  in 
females  neuralgic  pains  in  the  ovaries  and  womb. 

Examination  for  rectal  ulcer  is  made  with  the  speculum. 
The  ulcer  is  more  frequently  found  on  the  posterior  surface 
of  the  rectum,  but  often  on  the  anterior.  When  anterior,  the 
bladder  reflex  symptoms  are  more  marked.  On  examination, 
a  well  developed  rectal  ulcer  is  easily  recognized  by  the 
ragged  edges,  sometimes  elevated  and  gristly,  with  the 
mucus  discharge  occupying  the  space  between  them.  In 
some  cases  the  ulcer  presents  a  clear  cut  edge,  as  though  cut 
with  a  punch,  with  a  well  defined  offset  toward  its  floor.  If 
the  mucus  or  scum  is  wiped  off,  the  ulcerated  bottom  will  be 
exposed  to  view.  It  frequently  bleeds  and  is  quite  tender. 
Never  instruct  patients  to  take  an  injection  before  presenting 
themselves  for  an  examination  for  ulcer,  as  the  mucus  would 
thereby  be  removed.  In  well  marked  cases  it  could  be  dis- 
tinguished even  if  the  mucus  were  removed,  but  in  others, 
the  presence  Of  it  assists  its  location.  Rectal  ulcer  may  termi- 
nate in  a  cure,  deep  tissue  infiltration  and  death,  or  it  may, 
by  cicatrical  contraction,  cause  stricture  of  the  rectum. 

TREATMENT. 

When  seen  early,  the  cure  of  rectal  ulcer  is  not  difficult, 
but  when  seen  later,  after  considerable  of  the  mucous  mem- 
brane has  been  destroyed,  its  cure,  while  usually  certain,  is 
quite  tedious.  The  treatment  is  a  combination  of  home  and 
office  treatment.  The  latter  consists  of  first  wiping  away  the 
mucus  and  thoroughly  cleansing  the  ulcer  with  Hydrozone. 
applied  full  strength,  or  in  50%  solution,  with  a  small 
syringe.  The  ulcer  is  now  dried  and  a  solution  of  nitrate  of 
silver,  sixty  grains  to  the  ounce  of  distilled  water,  is  applied 
with  a  cotton  tipped  probe.  Eight  or  ten  drops  may 
be  dropped  on  the  ulcer  if  preferred,  instead  of  the  cotton 


RECTUM   AND  ANUS.  43 

application.  Alternating  with  this  application,  or  instead  of 
it.  the  ulcer  may  be  touched  in  a  similar  manner  with  a  solu- 
tion of  carbolic  acid  in  sperm  oil,  two  parts  of  the  former  to 
one  part  of  the  latter. 

Whenever  carbolic  acid,  or  any  mixture  containing 
twenty-five  or  more  per  cent,  of  it  is  applied  to  mucous  sur- 
faces, and  in  rectal  work  especially,  a  solution  of  equal  paits 
of  alcohol  and  water  should  be  applied  to  the  parts  touched 
with  the  acid  almost  immediately  afterward  to  neutralize  its 
effect  and  limit  its  action.  To  allow  a  strong  solution  of 
carbolic  acid  unlimited  action  on  mucous  surfaces  or  an  ulcer 
would  often  lead  to  undesirable  results.  After  having 
applied  the  dilute  alcohol  by  means  of  a  cotton  swab,  the 
ulcer  is  again  dried  and  dusted  with  Special  Protonuclein 
(Reed  &  Carnrick).  This  preparation  must  not  be  con- 
founded with  the  Protonuclein  which  is  intended  for  internal 
use.  It  is  stronger  than  the  latter  and  is  intended  for 
external  use  only.  Suppositories  containing  five  to  ten  grains 
of  the  Special  Protonuclein  are  also  of  value  and  one  may 
be  inserted  after  each  office  treatment,  and  once  daily  by  the 
patient.  As  the  following  home  treatment  is  used  at  night, 
and  the  ointments  in  the  morning,  the  suppository  may  be 
inserted  about  the  middle  of  the  day. 

Office  treatment  should  be  applied  twice  or  three  times  a 
week  in  the  first  part  of  the  treatment,  gradually  increasing 
the  intervals  between  treatments  as  the  case  improves. 

For  home  treatment,  the  following  "Ulcer  Specific"  is 
used : 

1^     Ext.  Witch  Hazel,  Distilled fl.  5  viss. 

Fl.  Ext.  Hydrastis,  aqueous fl.  5  iiss. 

Acid  Carbolic Tit  xxx. 

Glycerine    fl.  o  ix. 

Mix.  Mix  the  glycerine  with  the  acid  and  add  the 
hvdrastis.     Mix  well  and  add  the  witch  hazel  last. 


44  DISEASES    OF    THE 

Sig.  Mix  one-half  teaspoon ful  of  this  mixture  with 
one-half  teaspoonful  of  corn  starch  and  two  tablespoonfuls 
of  warm  water.  Inject  into  the  rectum  with  a  hard  rubber 
syringe  and  retain  all  night.  Repeat  every  night. 

If  there  is  occasional  bleeding,  the  following  "Ulcer 
Compound'"  will  give  better  results : 

1>      Monsell's  Solution  of  Iron fl.  3  iv. 

Glycerine fl.  5  iv. 

Acid   Carbolic fl.  5  ss. 

Ext.  Witch  Hazel.  Distilled fl.  5  j. 

Mix.  Sig.  Use  in  the  same  manner  as  the  "Ulcer 
Specific." 

Another  good  formula  for  use  in  ulceration  is : 

K      Fl.  Ext.  Hydrastis,  aqueous fl.  5  iv. 

Tr.    Calendula,   Lloyd's fl.  §  j. 

Tr.  Echafolta,  Lloyd's fl.  5  vj. 

Ext.  Witch'  Hazel,  Distilled,  q.  s.  ad. .    fl.  5  iv. 
Mix.     L~se  in  the  same  manner  as  the  "Ulcer  Specific." 

In  the  morning  after  the  patient's  bowels  have  been 
moved  and  are  at  rest,  the  following  ointment,  introduced 
into  the  rectum,  at  the  location  of  the  ulcer,  with  an  ointment 
injector,  will  be  a  useful  adjunct: 

R      Balsam  Peru o  ss. 

Ext.    Matico 5  ss. 

Sulphur  lac gr.  xlv. 

Ext.    Belladonna gr.  iij. 

Acid  Carbolic fl.  3  ss. 

Vaseline   o  iij- 

Mix.     Insert  the  usual  quantity  as  above  directed. 

This  treatment,  properly  and  diligently  applied  will 
result  in  a  cure  of  the  vast  majority  of  rectal  ulcers  in  from 
two  to  five  months.  Patients  should  be  impressed  with  the 
tedious  work  before  them,  and  their  best  efforts  and  assist- 
ance solicited. 


RECTUM   AND  ANUS.  45 


Fistula. 

Next  to  hemorrhoids,  fistula  is  the  most  common  disease 
that  attacks  the  rectal  and  anal  region.  Hospital  reports 
usually  place  fistula  first  in  point  of  frequency,  but  this  is 
due  to  the  fact  that  persons  with  hemorrhoids  do  not  apply 
to  the  public  institutions  for  relief  as  readily  as  those 
afflicted  with  the  more  serious  disease,  fistula.  In  private 
practice  hemorrhoidal  cases  are  first  in  point  of  frequency. 

Fistula  is  usually  the  result  of  an  abscess  which  has 
failed  to  heal  and  from  which  the  pus  burrows  its  way  out 
through  the  loose  areolar  tissue,  or  similar  burrowing  from 
an  abscess  which  has  never  been  open. 

This  process  may  continue  for  some  time  without  any 
special  inflammatory  action  and  without  discomfort  to  the 
patient,  thus  giving  the  impression  that  treatment  is  unneces- 
sary until  trouble  is  experienced.  This  is  certainly  unwise, 
yet  well  meaning  but  poorly  informed  physicians  have  been 
known  to  advise  patients  with  fistula  not  to  interfere  with 
it  until  compelled  to  do  so  on  account  of  inconvenience  and 
discomfort.  It  is  probably  true  in  all  cases  that  the  older 
the  fistula  the  more  difficult  and  stubborn  the  cure. 

VARIETIES. 

The  varieties  of  fistula  are  complete,  internal  incom- 
plete, external  incomplete  and  complex.  The  complete  fistula 
has  both  an  internal  and  external  opening,  an  internal  incom- 
plete has  an  internal  but  no  external  opening,  an  external 
incomplete  has  an  external  but  no  internal  opening,  and  a 
complex  fistula  is  one  with  a  number  of  openings,  branches, 
pockets  or  pouches  with  which  the  main  sinus  connects  at 
various  points. 

Further  division  is  usually  made  by  dividing  fistulae 
into  two  general  classes :  ( i )  Those  whose  origin  is  super- 
ficial and  (2)  Those  whose  origin  is  deep. 


46  DISEASES   OF   THE 

Those  of  superficial  origin  are  termed  anal  fistulae,  while 
those  of  deeper  origin  are  termed  rectal. 

Anal  fistulae  are  those  which  have  their  internal  opening 
between  the  two  sphincters,  where  a  slight  depression  is  felt, 
while  the  external  opening  is  usually  close  to  the  margin  of 
the  anus.  Rectal  fistulae  have  their  internal  openings  at 
various  distances  above  the  internal  sphincter.  From  a 
surgical  point  of  view  this  distinction  is  of  importance  as 
should  the  tissues  between  the  two  openings  be  divided  it 
is  apparent  that  in  anal  fistula  only  the  external  sphincter 
would  suffer,  while  in  rectal  fistula  both  of  the  sphincters 
would  be  involved  in  the  operation.  One  may  find  either  of 
the  four  varieties  of  fistulae  in  either  the  anal  or  rectal  region. 

DIAGNOSIS. 

Diagnosis  of  fistula,  when  the  conditions  about  the  anus 
and  rectum  are  carefully  observed,  is  usually  not  difficult, 
yet  the  almost  invisible  external  opening  of  a  fistula  may 
be  overlooked  during  several  apparently  careful  examina- 
tions. In  cases  of  this  sort  it  is  evident  that  patients  are  not 
acquainted  with  their  true  condition  but  come  to  the  physi- 
cian on  account  of  the  various  symptoms  which  they  may 
have. 

When  there  is  no  known  external  opening,  thus  not 
clearly  establishing  the  existence  of  a  fistula,  certain  symp- 
toms of  this  condition  should  be  borne  in  mind. 

The  presence  of  a  purulent  discharge  from  the  rectum, 
itching  at  and  about  the  anus,  swelling  and  the  formation 
of  a  tumor  which  on  palpation  gives  evidence  of  containing 
liquid  matter,  the  formation  of  an  abscess,  or  when  a  history 
of  abscess  is  given,  and  soreness  at  one  or  more  localized 
spots  in  the  ischio-rectal  region  should  always  lead  one  to 
suspect  fistula  and  careful  examination  made. 

When  symptoms  of  fistula  exist  the  most  careful 
examination  should  be  made  for  a  minute  opening  with  a 
lip-like  margin,  or  it  may  have  the  appearance  of  the  fresh 
sting  of  a  bee;  a  small  wheal  with  a  tiny  spot  in  the  center. 


RECTUM   AND  ANUS.  47 

ii  a  probe  is  pressed  into  this  opening  considerable  resistance 
may  be  offered,  but  the  probe  will  usually  penetrate  and  will 
often  ghde  freely  along  the  canal  and  appear  at  the  internal 
opening.      When  the  canal  is  tortuous  the  location  of  the 
internal  opening  is  difficult  or  impossible.  Too  much  pressure 
must  not  be  exerted  as  the  probe  can  without  very  much 
difficulty  be  pressed  through  the  tissues.     In  these  cases,  as 
in  all  others  where  the  internal  opening  has  not  been  located 
the  following  procedure  will  solve  the  problem      With  a 
suitable    syringe,    either    the    hypodermatic    with    the    dull 
canula  attached,  or  the  hard  rubber  in  cases  of  larger  external 
openings,  inject  sufficient  milk  to  distend  the  fistulous  track- 
while  with  the  speculum  introduced  the  interior  is  observed 
and  the  escape  of  the  milk  noticed. 

Should  no  internal  opening  exist  the  distension  caused 
by  the_  injection  of  the  milk  will  enable  the  examiner  to 
determine  the  course  and  extent  of  the  pouch  and  thereby 
be  guided  tor  future  treatment;  yet  in  the  obscure  external 
openings,  when  one  suspects  fistula  from  the  presence  of 
discharge  from  the  rectum,  the  internal  opening  must  of 
necessity  exist  if  there  is  a  fistula.  It  may  however  be  a 
true  internal  incomplete  fistula. 

External  openings  of  fistulae  may  appear  at  unexpected 
places.  Matthews  has  reported  a  case  which  had  two 
external  openings,  one  over  the  sacrum  and  the  other  over 
the  last  lumbar  vertebra.  In  this  case  the  abscess  began 
several  inches  distant  from  the  rectum  and  the  pus  bur- 
rowed in  an  opposite  direction  and  had  no  connection  with 
the  rectum. 

ABSCESS. 
When  seen  early,  at  the  beginning  of  or  during  the 
existence  of  an  abscess  in  this  region,  whether  superficial  or 
deep-seated,  prompt  treatment  should  be  instituted  by  the 
application  of  hot  poultices  to  hasten  its  formation,  and  the 
pus  evacuated  as  soon  as  fluctuation  is  noticed.  After  treat 
ment  will  then  be  similar  to  the  same  condition  in  any  other 
location. 


48  diseases  of  the; 


TREATMENT. 

Treatment  for  fistula  may  be  either  by  surgical  means, 
by  the  use  of  cauterants,  caustics,  escharotics  and  antisep- 
tics, or  by  the  ligature.  In  the  former  and  latter  treatment 
the  object  is  the  division  of  the  tissues  between  the  internal 
and  external  openings,  while  by  the  method  of  local  applica- 
tions the  fistulous  track  is  cleansed  and  stimulated  to  granu- 
lations and  subsequent  healing  of  the  parts. 

The  treatment  by  local  applications  is  not  applicable  to 
all  cases,  yet  it  is  certain  that  a  much  larger  percentage  are 
curable  than  the  advocates  of  the  knife  are  willing  to  admit, 
and  it  is  also  worthy  of  mention  that  fistulae  which  have 
resisted  treatment  by  local  means  and  which  eventually 
drifted  into  the  hands  of  our  surgical  friends,  were  dis- 
charged in  a  condition  infinitely  worse  than  before  the  cut- 
ting operation.  It  is  true  that  thousands  of  fistulae  are 
cured  by  surgical  means  and  the  patients  discharged  in 
perfect  condition,  yet  a  large  number  of  those  so  treated 
would  have  been  as  readily  cured  by  the  milder  means  with- 
out the  liability  to  greater  woes.  Division  of  the  tissues, 
often  including  the  sphincters,  is  liable  to  cause  permanent 
incontinence  of  feces,  which  as  Dr.  Kelsey  says  "is  always 
considered  by  the  patient  a  very  poor  exchange  for  a  fistula 
which  was  causing  comparatively  little  suffering  or 
annoyance." 

I  do  not  hesitate  to  say  that  while  my  impressions  of 
surgical  means  for  the  cure  of  fistula  remain  as  they  now 
are,  I  would  not  employ  this  method  except  in  small  anal 
fistulae  where  but  a  few  fibres  of  the  external  sphincter  are 
involved. 

Anal  fistulae,  those  which  involve  only  the  external 
sphincter,  having  their  internal  opening  between  the  two 
sphincter  muscles  can  be  laid  open  under  local  anesthesia 
only,  but  for  the  rectal  variety,  surgical  anesthesia  must  be 
induced.     The  process  of  opening  the  track  of  the  fistula 


RECTUM   AND  ANUS.  49 

involves  the  use  of  the  grooved  director  and  following"  its 
groove  with  a  sharp  bistoury,  dividing  the  tissues.  Details 
of  this  operation  can  be  found  in  text  books  on  surgery. 

TREATMENT  BY  THE  LIGATURE. 

The  use  of  the  ligature  for  division  of  the  tissues 
between  the  two  openings  of  a  fistula  can  be  traced  to  remote 
ages.  It  is  said  to  have  been  recommended  by  Hippocrates, 
the  father  of  medicine  who  lived  three  or  four  centuries  B. 
C,  and  its  use  has  been  revived  from  time  to  time.  Its 
advantages  are  chiefly  that  no  anesthetic  is  required,  no  cut- 
ting operation  is  performed  and  there  is  no  loss  of  blood. 

This  method  is  adapted  only  to  simple  sinuses  and  not 
to  fistulae  of  the  complex  variety.  Two  varieties  of  ligature 
are  employed  and  there  are  also  two  methods  of  division  of 
the  tissues.     These  are  ulceration  and  strangulation. 

If  it  be  decided  to  divide  the  tissues  by  ulceration  the 
silk  ligature  is  usually  used  and  simply  tied  in  a  loose  knot. 
Jt  usually  accomplishes  its  Avork  in  two  to  three  weeks. 

Better  results  are  obtained  if  the  elastic  ligature  is  used 
and  the  tissues  divided  rapidly  by  strangulation.  The  process 
is  as  follows.  After  a  thorough  evacuation  of  the  bowels, 
and  douching  of  the  rectum  with  a  tea  spoonful  of  boracic 
acid  in  a  pint  of  warm  water,  the  patient  is  ready  for  the 
treatment.  Thread  a  silver  probe  or  aneurism  needle  with 
silk  thread,  to  which  a  rubber  ligature  is  attached,  pass 
the  probe  through  the  fistula  from  the  outside  until  the 
threaded  point  is  within  the  rectum.  Cut  the  thread  and 
withdraw  the  probe  backwards  through  the  fistula.  The 
thread  should  be  four  or  six  inches  long,  so  that  it  can  be 
handled  easily.  With  forceps  grasp  the  thread  in  the  rectum 
and  draw  the  ligature  through  the  fistula.  An  artery  forceps 
attached  to  the  outside  end  of  the  ligature  will  prevent  its 
being  drawn  into  the  opening.  Pass  both  ends  of  the  liga- 
ture through  a  perforated  shot  or  piece  of  lead  ,and  draw 
them  moderately  tight,  and  compress  the  lead  with  a  tooth 
forceps,  as  rubber  ligatures  do  not  tie  well.     This  method 


50  DISEASES   OF  THE 

will  divide  the  tissues  in  from  four  to  ten  days,  depending  on 
the  bulk  of  tissue  enclosed.  If  the  ligature  tears  before 
cutting  itself  out,  repeat  the  operation.  The  fistula  should 
be  cleansed  daily  with  diluted  Hydrozone.  Use  no  oint- 
ment, as  the  rubber  will  decompose  if  brought  in  contact 
with  it.  After  cutting  through,  dress  antiseptically  after  the 
manner  of  other  open  sores. 

The  elastic  ligature  has  the  advantage  over  the  silken 
one,  in  that  it  exerts  its  function  continuously  and  evenly 
and  requires  no  readjusting  unless  in  case  of  an  accidental 
tearing.  When  silk  is  used  for  the  strangulation  method  it  is 
tied  very  tightly  around  the  tissues  and  should  be  readjusted 
every  five  to  seven  days. 

The  elastic  ligature  used  is  about  one  tenth  of  an  inch 
in  diameter,  yet  while  in  action,  being  tense,  its  cutting  edge 
is  very  much  diminished  and  as  the  intervening  tissues  are 
cut  through  its  force  becomes  lessened. 

When  the  amount  of  tissue  to  be  divided  is  considerable 
the  ligature  will  probably  not  cut  its  way  out  on  account  of 
the  relaxation  which  follows  its  passage  through.  In  these 
cases  it  is  best  to  begin  with  the  ligature  moderately  tight 
and  readjust  it  every  two  or  three  days. 

This  method  of  treating  fistula  is  endorsed  by  Dr. 
Candler  of  Chicago,  in  the  following  extract  of  an  article 
by  him  in  the  Surgical  Clinic : 

"Taking  the  ordinary  complete  fistula,  investigation  will 
show  that  it  is  not  a  mere  straight  channel  of  even  diameter. 
In  nine  cases  out  of  ten  the  two  terminals  will  be  of  small 
caliber,  but  between  them  will  be  a  cavity  varying  in  size 
and  shape.  This  cavity  often  has  canals  ramifying  in  all 
directions.  When  the  patient  will  submit  to  having  the 
fistula  slit  up  and  the  walls  dissected  out  we  get  a  radical 
cure,  but  people  do  not  like  steel  around  their  anus,  so  the 
next  best  thing  to  use  is  the  ligature — or  in  very  mild  cases 
where  the  caliber  is  small  and  the  fistula  straight  and  com- 
plete—curettage  and  packing. 


RECTUM   AND  ANUS.  5 1 

"A  fistula  presenting,  thoroughly  wash  the  parts  with  a 
strong  antiseptic  solution,  (i-iooo  bichloride  will  do),  then 
gradually  dilate  the  sphincter  and  with  a  flexible  probe  find 
the  main  orifices ;  then  with  a  small  nozzle  syringe  flush  out 
the  tract;  at  the  same  time  with  the  finger  and  thumb  try 
to  outline  the  shape  and  extent  of  the  central  pouch.  If 
this  seems  to  be  extensive  it  is  better  to  inject  into  it  a  solu- 
tion of  ichthyol  and  boro-glyceride  with  glycerine,  in  the 
following  proportions : 

^      Ichthyol    5  j. 

Boro-glyceride    5  ij. 

Glycerine 5  iv. 

Mix. 

"Repeat  this  injection  daily  for  three  days  and  at  the  end 
of  that  time  wash  again  most  thoroughly  and  then  pass  the 
elastic  ligature.  Draw  the  two  ends  out  and  clamp  them 
with  a  metal  button  or  lead  bullet,  making  just  enough  ten- 
sion to  firmly  constrict  the  tissue  embraced.  Have  the 
patient  call  on  you  in  twenty-four  hours  and  then  insert  the 
nozzle  of  your  syringe  alongside  the  rubber  and  wash  out  the 
tract.  Then  tighten  up  on  the  ligature.  When  the  patient 
calls  again  the  work  may  be  done;  if  not  repeat. 

"The  advantage  of  taking  the  trouble  of  cleansing  the 
parts  is  that  you  give  the  parts  behind  the  ligature  a  chance 
to  heal  under  fairly  aseptic  conditions,  while  if  you  leave 
things  alone  you  have  a  cutting  and  granulating  going  on  in 
the  presence  of  filth. 

"All  blind  fistulas  can  be  treated  this  way  by  making 
them  complete,  and  after  all,  this  is  the  best  thing  to  do.  A 
blind  external  fistula  may  often  be  cured  by  curetting 
under  cocaine  and  then  packing  for  twenty-four  hours  with 
iodoform  gauze.     Then  dust  in  Protonuclein  and  pack. 

"By  this  method  the  majority  of  rectal  fistulae  can  be 
'treated  at  home'  with  perfect  success  and  much  profit. 
During  treatment  the  patient  should  be  kept  saturated  with 
calcium    sulphide.      After    passing    the    ligature,    keep    the 


52  DISEASES   OF  THE 

bowels  closed  for  forty-eight  hours  then  open  them  with 
a  full  dose  of  castor  oil  or  saline.  Order  the  parts  washed 
after  each  stool  with  a  mild  creosol  or  similar  solution." 

TREATMENT  BY  LOCAL  APPLICATIONS. 

Local  applications  of  certain  remedies  which  combine 
cleansing  antiseptics,  cauterants,  caustics  and  tissue  stimu- 
lants form  a  treatment  for  fistula  that  at  once  appeals  to  the 
physician  as  well  as  patient.  As  a  cleansing  and  antiseptic 
agent  Hydrozone  occupies  the  first  position  and  as  such  is 
endorsed  by  many  writers  in  the  treatment  of  fistula.  It 
penetrates  deeply  into  the  ulcerated  tissues,  destroys  all  pus 
formations  and  stimulates  granulations. 

Bichloride  of  mercury  is  also  of  value  especially  in 
cases  where  there  is  marked  decomposition  or  foul  odor. 
Permanganate  of  potassium  is  also  of  considerable  value  in 
the  latter  conditions. 

Carbolic  acid,  Nitrate  of  silver  and  Nitrate  of  copper 
are  probably  the  most  useful  cauterants  and  caustics. 

Carbolic  acid  may  be  used  in  ninety-five  or  in  not  less 
than  seventy-five  per  cent,  solution.  When  the  latter  is 
employed  the  best  diluent  is  sperm  or  olive  oil. 

Nitrate  of  silver  is  best  employed  in  solutions  of  forty 
to  sixty  grains  to  the  ounce  of  water. 

Nitrate  of  copper  is  applied  by  means  of  passing  a 
copper  probe  which  has  been  dipped  into  pure  nitric  acid 
along  the  fistulous  canal  after  the  usual  cleansing  procedures. 

As  a  tissue  stimulant  Protonuclein  (Reed  &  Carnrick) 
is  of  pronounced  value.  Here,  as  in  rectal  ulcer,  the  Special 
preparation  is  employed.  By  a  stimulation  of  the  white 
corpuscles  and  inciting  them  to  greater  activity  in  combating 
the  destructive  changes  which  are  going  on,  it  acts  as  a  physi- 
ological cell  irritant  and  causes  a  proliferation  of  normal, 
healthy  granulation  cells. 

Being  prepared  for  the  application  of  this  treatment  the 
lower  bowel  is  cleansed  by  a  solution  of  Hydrozone.  fifty 


RECTUM   AND  ANUS.  53 

per  cent,  and  the  fistula  is  irrigated  with  Hydrozone,  full 
strength. 

For  the  irrigation  of  the  bowel  any  suitable  syringe  is 
used,  but  for  the  sinus  the  hard  rubber  syringe  with  long 
nozzle  is  best,  as  all  parts  of  the  canal  can  be  reached  and 
considerable  force  used. 

The  introduction  of  the  nozzle  of  the  syringe  will  some- 
times cause  some  little  excitation  of  the  internal  surfaces  and 
assist  the  cure,  but  it  is  good  routine  practice  to  slightly 
irritate  or  scarify  the  track  of  the  fistula  by  means  of  a  probe 
slightly  roughened,  and  passing  it  up  and  down  several 
times. 

The  carbolic  acid  of  the  desired  strength  having  been 
prepared,  attach  a  silver  probe  canula  to  an  ordinary  hypo- 
dermatic syringe  and  draw  some  of  the  acid  into  the  barrel 
of  the  syringe.  If  an  internal  opening  exists  place  a  wad  of 
cotton  around  the  tip  of  the  fore-finger  of  one  hand  and 
insert  it  into  the  rectum  and  over  the  opening,  so  as  to 
prevent  any  of  the  acid  from  entering  the  bowel.  Insert 
the  canula  well  up  in  the  fistula,  practically  in  contact  with 
the  cotton  pressed  on  the  opening,  and  as  the  canula  is 
slowly  withdrawn  press  out  the  acid,  a  drop  at  a  time  until 
the  external  opening  is  reached.  Press  along  the  canal 
with  the  finger  a  few  moments  for  the  purpose  of  distributing 
the  acid,  and  press  out  the  excess  if  there  be  any.  After 
a  minute  or  two  pass  a  probe,  tipped  with  cotton  and  wet 
with  dilute  alcohol,  up  and  down  the  track  of  the  fistula  and 
immediately  afterward  syringe  it  out  with  a  little  water. 
These  applications  are  made  once  a  week  or  once  in  two 
weeks  according  to  the  indications  of  the  case.  After  drying 
the  parts  apply  Special  Protonuclein  throughout  the  fistula 
by  means  of  a  powder  blower  or  other  suitable  means.  This 
part  of  the  treatment  should  be  performed  twice  a  week, 
preceded  by  a  cleansing  irrigation  with  Hydrozone. 

Treatment  by  Nitrate  of  Silver  solution  is  applied  in  the 
same  manner  as  the  Carbolic  Acid,  but  this  can  be  used  more 
freely  than  the  acid,  in  fact  sufficient  should  be  used  to  reach 


54  DISEASES  OF  THE 

all  parts  of  the  fistulous  track,  the  excess  being  allowed  to- 
run  out.  During  this  treatment  the  external  parts  should 
be  lightly  covered  with  vaseline  to  prevent  discoloration  and 
irritation  of  the  skin  as  the  excess  escapes. 

The  carbolic  acid  seems  most  beneficial  in  the  early 
part  of  the  treatment,  while  nitrate  of  silver  is  indicated 
when  the  granulations  are  slow  in  forming  and  the  surfaces 
indisposed  to  heal.  However  either  remedy  is  used  almost 
exclusively  by  some  operators  while  others  alternate  thera 
to  advantage. 

Be  careful  that  the  external  opening  is  not  healed  before 
the  interior  has  done  so.  Internal  incomplete  fistula,  is  not 
easily  treated  in  this  manner,  and  self  treatment  by  the 
patient,  using  the  Ulcer  Specific  given  under  rectal  ulcer,  as 
directed  there,  can  be  employed.  In  connection  with  the 
treatment  just  given,  an  occasional  douching  of  the  fistulous 
canal  with  bichloride  solution,  i-iooo  will  be  beneficial. 
Keep  the  canal  clean  by  daily  flushings  with  a  2%  Carbolic 
acid  solution,  except  after  Protonuclein  has  been  thrown 
into  the  fistula.  This  should  be  allowed  to  remain  undis- 
turbed 36  hours.  Wearing  a  piece  of  iodoform  gauze  in  the 
canal,  packed  in  lightly  and  renewed  once  every  two  days  is 
often  beneficial,  acting  both  as  an  irritating  and  stimulating 
agent.  Iodine  has  been  recommended  for  injecting  fistulae 
but  the  remedies  mentioned  are  more  preferable.  The 
injection  of  pure  eucalyptol,  thoroughly  permeating  every 
part  of  the  fistula  is  often  followed  by  good  results.  Even 
when  carbolic  acid  or  nitrate  of  silver  are  used  an  occasional 
injection  of  eucalyptol  will  be  of  benefit  and  hasten  the 
healing  process. 

Ointments  are  of  little  value  in  this  disease,  in  fact  it 
is  a  question  whether  the  introduction  of  oils  and  fats  is 
not  decidedly  contraindicated.  Cleanliness,  antiseptics  and 
stimulation  being  the  three  leading  points,  little  is  to  be 
gained  by  other  measures. 


RECTUM    AND   ANUS.  55 

DR.  MASON'S  TREATMENT  FOR  FISTULA 
WITHOUT  CUTTING. 

This  treatment  is  quite  similar  to  that  used  by  Dr. 
Bennett,  Austin,  Tex.  "Prepare  the  patient  by  the  use  of 
cathartic  medicines,  enemata  and  restricted  diet  so  that  the 
colon  will  be  as  nearly  empty  as  possible.  Syringe  the 
fistulous  track  with  a  solution  of  peroxide  of  hydrogen  and 
follow  with  plain  water.  After  this  is  done  anesthetize  the 
track  with  a  ten  per  cent,  solution  of  cocaine.  Now  fill  a 
good  sized  rubber  or  glass  syringe  with  a  saturated  solution 
of  nitrate  of  silver.  Place  a  rubber  finger  cot  on  the  index 
finger  and  place  it  firmly  over  the  internal  opening  of  the 
fistula  if  it  can  be  found. 

It  can  usually  easily  be  located  by  careful  search  with 
the  finger  in  the  bowel.  Put  cosmoline  on  the  skin  to 
prevent  it  from  being  burned  by  the  fluid  that  runs  out. 
Introduce  the  syringe  point  firmly  into  the  external  opening, 
completely  closing  it,  and  with  the  finger  over  the  internal 
opening,  force  the  intervening  cavity  full  of  the  silver  solu- 
tion, holding  it  there  for  a  short  time.  This  will  fill  to  the 
fullest  extent  not  only  the  main  track  but  also  any  branches 
that  may  be  present.  Remove  the  syringe  and  with  the 
finger  massage  the  fistula  thoroughly  to  bring  the  medicine 
into  contact  with  all  parts.  In  case  the  internal  opening 
cannot  be  located,  force  the  solution  in  just  the  same,  but 
before  doing  this  inject  an  ounce  of  sweet  oil  into  the  rec- 
tum so  that  should  any  of  the  solution  enter  the  bowels  no 
harm  will  be  done.  Nothing  should  be  put  into  the  fistula 
after  the  silver  solution  has  been  injected.  Unless  the 
external  opening  is  quite  large  a  crucial  incision  should  be 
made  to  secure  a  good  drainage.  The  entire  lining  of  the 
fistula  will  slough  away  in  five  or  six  days  and  healthy 
granulations  spring  up  to  take  its  place.  The  external 
opening  must  be  kept  well  dilated  so  as  to  allow  free  drain- 
age, and  a  moist  corrosive  sublimate  dressing  applied  for 


56  DISEASES  OF   THE 

a  few  days.  If  the  first  treatment  is  not  sufficient  to  cure, 
repeat  the  operation  after  two  or  three  weeks." 

The  general  health  of  persons  having  fistulae  is  usually 
below  par,  especially  when  the  disease  has  existed  for  some 
time  and  the  discharge  profuse.  There  has  been  some 
inclination  among  writers  to  associate  fistula  with  pulmonary 
tuberculosis,  yet  beyond  that  predisposition  which  a  condi- 
tion of  lowered  vitality  affords,  it  is  probably  erroneous  to 
associate  the  two.  It  may  also  be  said  that  the  systemic 
conditions  which  predispose  to  tubercular  disease  also  render 
the  person  more  liable  to  fistula. 

Persons  who  are  poorly  nourished,  anemic,  and  in  whom 
fat  is  noticeably  absent,  have  but  little  power  of  resistance 
against  the  pathogenic  organisms  which  are  liable  to  be 
introduced  into  the  body  and  proliferate  there,  and  conditions 
which  in  the  robust  and  well  nourished  are  scarcely  noticed, 
here  become  painfully  apparent. 

Allingham  of  London,  who  has  had  ample  opportunity 
for  observation,  reports  that  of  fistulous  patients  seen  during 
a  period  of  seven  years,  fifteen  per  cent,  were  more  or  less 
tubercular,  although  many  of  them  were  thus  classified  who 
merely  gave  evidence  of  predisposition  to  tuberculosis  or 
presented  some  of  the  early  signs  of  the  disease. 

Another  writer  who  has  made  observation  in  this  con- 
nection says :  about  twelve  per  cent,  of  fistulous  patients 
are  subject  to  tuberculosis,  and  about  five  per  cent,  of  tuber- 
cular subjects   have  fistula. 

From  this  it  will  be  seen  that  the  percentage  is  not 
sufficiently  high  to  warrant  any  other  connection  between  the 
two  conditions,  than  the  one  previously  mentioned ;  the  pre- 
disposition which  a  condition  of  lowered  vitality  affords. 

In  this  connection  it  is  not  necessary  to  more  than 
remind  the  practitioner  to  attend  to  the  general  treatment  of 
these  patients.  Much  good  can  be  accomplished  by  the 
administration  of  tonics,  reconstructives,  tissue  builders, 
etc.  Iron  and  arsenic  are  especially  valuable,  also  the  hypo- 
phosphites  and  cod  liver  oil. 


RECTUM    AND  ANUS. 


Rectal  and  Anal  Fissure,  or 
Irritable  Ulcer. 

Fissure  of  the  anus  and  rectum  is  probably  the  most 
painful  disease  that  affects  this  region.  As  implied  by  its 
name,  this  disease  consists  of  a  fissure  or  crack  in  the  mucous 
membrane  of  the  lower  part  of  the  rectum  and  usually 
extends  outward  involving  the  anus. 

As  the  anus  is  that  point  at  which  mucous  membrane 
ends  and  skin  begins,  it  is  evident  that  a  fissure  in  that 
locality  involves  both  the  anus  and  lower  part  of  the  rectum. 
The  length  of  a  fissure  may  vary  from  one  fourth  to  three 
fourths  of  an  inch,  and  in  depth  it  may  appear  only  as  a 
delicate  red  line  or  it  may  extend  downward  through  the 
mucous  membrane  and  connective  tissue  to  the  sphincter 
muscle.     The  edges  may  be  smooth,  or  ragged  and  everted. 

The  symptoms  of  fissure  are  first,  pain.  This  may  be 
?o  severe  that  the  victim  will  suffer  the  most  excruciating 
agony.  Pain  is  more  acute  during  defecation  and  continues 
.for  several  hours  afterward.  When  the  fissure  is  located 
over  the  sphincter,  the  pain  usually  begins  with  the  passage 
of  feces.  When  situated  higher,  above  the  muco-cutaneous 
junction,  the  pain  is  more  severe  an  hour  or  two  after  stool, 
and  is  of  dull  aching  character. 

Fissure  is  easilv  recognized.  An  ocular  examination 
being  all  that  is  necessary.  When  a  fissure  has  existed  for 
some  time,  a  peculiar  cutaneous  excrescence  appears  at  the 
anal  verge,  which  by  some  is  considered  a  diagnostic  sign, 
but  its  absence  does  not  imply  that  no  fissure  exists.  With 
the  finger,  draw  the  mucous  membrane  downward  and  the 
fissure,  if  present,  can  readily  be  recognized.  When  it 
extends  downward,  involving  the  skin,  its  presence  is  notice- 
able immediately  on  inspection. 


58  DISEASES   OF   THE 

On  separating  the  folds  of  mucous  membrane  which 
sometimes  overlap  the  fissure,  and  following  its  course 
upward,  the  fissure  will  be  found  to  lead  to  a  small  ulcer, 
most  frequently  elliptical  in  shape,  which  is  extremely- 
irritable. 

TREATMENT.  The  surgical  treatment  of  this  con- 
dition consists  of  dilating  the  sphincters,  advised  by  all 
authors  of  text  books  and  taught  in  all  schools.  This 
method  of  treatment  is  not  uniformly  curative  and  has  dis- 
advantages which  appeal  to  the  patient.  General  anesthesia 
is  probably  the  principal  objection.  Patients  should  be 
fully  informed  of  the  slow  progress  that  will  be  made  by 
local  treatment,  yet  withal,  the  majority  will  prefer  it. 

LOCAL  TREATMENT. 

Local  treatment  must  be  directed  toward  converting  the 
fissure  into  a  simple  sore.  This  is  done  by  applications  of 
carbolic  acid,  pure.  The  applications  may  be  made  without 
the  use  of  the  speculum,  if  the  fissure  can  be  exposed  to  view, 
but  if  not  the  speculum  must  be  used.  A  small  speculum 
should  be  used  as  the  sphincters  are  very  irritable  in  these 
cases  and  contract  readily.  Before  inserting  the  speculum, 
the  parts  may  be  cocainized  by  the  application  of  a  10% 
solution,  applied  on  cotton.  The  speculum  is  now  well  oiled 
and  passed  into  the  rectum,  the  fenestrum  of  same  being 
so  placed  that  when  the  slide  is  removed,  the  fissure  will 
appear  in  the  opening.  A  probe  is  now  tipped  with  cotton 
and  dipped  into  pure  carbolic  acid  and  drawn  through  the 
fissure  and  over  the  ulcer  several  times  until  it  has  turned 
white.  The  excess,  if  any,  should  now  be  wiped  off  and  a 
bit  of  cotton  twisted  to  the  length  of  the  fissure  and  laid 
into  it.  Two  or  three  applications  of  this  nature  will  convert 
the  fissure  into  a  simple  sore,  the  healing  of  which  can  be 
stimulated  by  applications  of  nitrate  of  silver,  forty  grains 
to  the  ounce.  The  ragged  edges  can  be  trimmed  off  or 
cauterized  with  stick  nitrate  of  silver  or  pure  carbolic  acid. 
The  little  tab  or  cutaneous  excrescence  should  be  removed. 


RECTUM   AND  ANUS.  59 

If  soreness  follows  the  application  of  the  acid,  a  sup- 
pository of  opium  and  belladonna  may  be  inserted  as 
required.  After  the  fissure  has  been  thus  treated  and  its 
irritability  removed,  the  patient  is  given  an  ointment  for 
thorough  applications  externally.     The  formula  for  this  is, 


I£     Acid    Salicylic gr.  xx-xxv. 

Morphine  Sulphate gr.  iss. 

Ext.  Belladonna gr.  xx. 

Ung.  Lead  Subacetate 5  ij. 

Simple    Cerate 5  ij . 

Mix.  If  this  ointment  causes  pain,  lessen  the  amount  of 
salicylic  acid,  until  later  in  the  treatment,  and  gradually 
increase.  As  salicylic  acid  has  the  power  to  disorganize 
calloused  tissue,  its  use  is  indicated  especially  when  the 
rough  and  tough  edges  exhibit  an  inclination  to  resist  other 
treatment. 

Dr.  Geo.  J.  Monroe,  of  Louisville,  a  well  known  writer 
and  rectal  specialist,  treats  fissure  by  forcible  dilatation  or 
by  local  applications.  For  treatment  by  the  latter  method, 
he  proceeds  as  follows. 

Wash  the  parts  with  tar  soap  and  water,  then  wash 
with  hydrogen  dioxide;  saturate  absorbent  cotton  with  a 
20%  solution  of  cocaine,  press  a  part  of  this  into  the  anus 
and  a  part  on  the  outside.  In  eight  or  ten  minutes  remove 
this,  apply  hydrogen  dioxide  to  fissure  and  follow  this  with 
an  application  of  balsam  Peru.  Repeat  this  daily.  He  also 
uses  nitrate  of  silver  applications,  three  grains  to  the  ounce, 
applied  with  a  camel's  hair  pencil.  This  may  be  repeated 
every  other  day.  The  nitrate  of  silver  treatment  is  not  used 
in  connection  with  the  one  in  which  balsam  Peru  is  used, 
unless  to  stimulate  the  ulcer.  In  addition  to  either  treatment, 
be  gives  patients  the  following  ointment. 


6o  DISEASES   OF   THE 

E      Menthol, 

Carbolic  Acid aa  5  j . 

Sweet  Almond  Oil fl.    o  ij. 

Zinc  Oxide 3  ss. 

Benzoinated  Lard,  or 

Simple    Cerate §  iv. 

Mix.     Apply  twice  a  day. 

Dr.  Agnew's  treatment,  aside  from  dilatation  in  patients 
who  will  not  allow  this  operation  is  as  follows :  He  uses 
carbolic  acid  applications,  to  convert  the  fissure  into  a  simple 
sore,  and  after  the  fissure  has  lost  its  irritability,  he  snips 
off  the  tough  edges  with  a  scissors,  and  supplies  the  patient 
with  the  following  ointment  for  use  at  home. 

R>     Acid    Salicylic gr.  xv-xxx. 

Morphine  Sulphate gr.  i-ij. 

L  ng.    Belladonna .3  ss. 

Mix.    Apply  twice  daily. 

Instead  of  salicylic  acid,  bichloride  of  mercury  may  be 
employed  in  the  following  manner. 

1^      Mercuric  Chloride,  Gorros gr.  ij-iv. 

Morphine    Muriate gr.  ij-iv. 

Ung.    Belladonna 5  j. 

Mix.     Use  twice  daily. 

If  there  is  an  indisposition  to  heal,  after  the  irritability 
is  lessened,  and  the  ragged  edges  removed,  he  applies  nitrate 
of  silver,  stick,  to  the  inactive  sore  to  stimulate  it.  Apply 
gently  so  as  to  leave  a  thin  coating  of  albuminate  of  silver 
over  it.     Bichloride  of  mercury  may  also  be  used  for  this 


RECTUM    AND    ANUS.  .  6l 

purpose,  gr.  ss.  to  water  fl.  5  iv.  Apply  with  a  camel's  hair 
brush  after  the  sore  has  been  dried  with  absorbent  cotton. 
Two  grains  of  muriate  of  morphine,  added  to  the  bichloride 
solution  will  render  it  painless.  Cleansing  with  peroxide  of 
hydrogen  and  filling  the  fissure  by  a  covering  of  flexible 
collodion,  after  cleansing  with  peroxide  is  recommended,  as 
it  supplies  protection  and  rest  to  the  parts.  For  the  purpose 
of  converting  the  fissure  into  a  simple,  tolerant  ulcer,  he 
also  advises  the  use  of  his  hemorrhoidal  fluid,  injected  in  two 
or  three  places  along  the  fissure,  into  and  beneath  the  bed 
of  the  ulcer,  one  or  two  drops  being  used.  This  produces 
a  slough  and  at  once  brings  ease  to  the  patient.  Deep  fissures 
should  not  be  so  treated,  as  sloughing  of  the  sphincter  might 
result. 

Another  treatment  consists  of  applying  a  strong  solution 
of  cocaine  to  the  parts,  to  facilitate  the  introduction  of  the 
speculum,  after  which  a  pledget  of  cotton,  wet  with  carbolic 
acid,  pure,  is  laid  in  the  track  and  allowed  to  remain  for  a 
few  moments.  This  produces  complete  anesthesia  of  the 
parts  and  a  very  sharp  bistoury  is  then  gently  drawn  through 
the  bottom  of  the  track,  two  or  three  times,  or  sufficiently 
often  to  be  sure  that  a  little  depth  has  been  reached.  Finally 
the  point  of  the  knife  is  pressed  into  the  tissue  more  firmly 
at  several  places,  as  if  making  punctures.  The  after  treat- 
ment is  the  same. 


62  DISEASES   OF  THE 

TREATMENT  OF  FISSURE  BY  DILATATION  OF 
THE  SPHINCTERS. 

The  objects  in  view  when  treating  fissure  by  dilating  the 
sphincters  are  to  rupture  the  bed  of  the  fissure  and  changing 
the  form  of  the  attending  ulcer,  and  to  give  the  parts  the 
necessary  rest  by  the  paralysis  of  the  muscles. 

The  operation  is  performed  in  the  manner  described  in 
the  chapter  devoted  to  that  subject. 

After  dilatation  the  fissure  should  be  examined  and  if 
the  surrounding  mucous  membrane  is  thickened  or  overhangs 
along  the  edges  it  should  be  trimmed  off.  The  skiny  tab 
usually  accompanying  fissure  should  also  be  removed,  after 
which  the  ulcer  and  torn  fissure  are  dusted  with  either  aristol 
or  iodoform,  preferably  the  latter,  and  a  suitable  dressing 
applied  and  held  by  a  T  bandage. 

If  pain  or  soreness  follow,  apply  hot  water  externally 
and  introduce  a  suppository  of  either  opium  or  cocaine,  or 
opium  and  belladonna.  Two  or  three  days  should  elapse 
before  a  movement  of  the  bowels  takes  place,  and  if  the 
flushing  previous  to  the  operation  was  of  sufficient  quantity 
there  will  be  no  desire  for  a  movement  before  this.  Should 
there  be  an  indisposition  to  heal,  especially  the  ulcer,  touch 
lightly  with  carbolic  acid,  seventy-five  per  cent,  solution 
after  a  cleansing  with  hot  bichloride  solution,  i-iooo. 

The  use  of  the  salicylic  ointment  will  also  be  of  service 
in  assisting  the  removal  of  the  superfluous  tabs  of  mem- 
brane and  promote  the  healing  process. 


RECTUM    AND    ANUS.  63 


Prolapse  of  the   Rectum. 

Prolapse  of  the  rectum  frequently  occurs  in  children, 
and  in  adults  is  not  by  any  means  rare.  This  condition  may 
appear  in  three  forms  :  Partial,  when  the  prolapsed  portion 
consists  of  mucous  membrane  alone.  Complete,  when  the 
prolapsed  portion  consists  of  not  only  mucous  membrane 
but  also  the  muscular  coats  of  the  rectum.  The  other  form 
is  really  invagination  of  the  bowel  as  in  this  condition  the 
upper  or  movable  part  of  the  rectum  prolapses  into  the  lower 
part. 

Fortunately  the  latter  condition  is  rare,  as  it  is  extremely 
serious  and  unless  seen  in  its  early  stage  almost  invariably 
requires  an  operation. 

Partial  prolapse  is  most  frequently  associated  with 
internal  hemorrhoids,  the  protrusion  of  which  force  the 
mucous  membrane  down  and  beyond  the  verge  of  the  anus. 
In  these  cases  a  cure  of  the  piles  will  cure  the  prolapse. 
This  form  also  occurs  frequently  in  children  and  is  due  to 
diarrhoea,  worms  or  other  irritations  which  cause  the  child 
to  bear  down.  Simple  prolapse  of  the  mucous  membrane 
but  seldom  exceeds  a  length  of  two  inches,  is  thin  to  the 
touch  and  gives  evidence  of  being  mucous  membrane  only. 
When  the  protrusion  is  longer,  thicker  and  more  fleshy  to 
the  touch  it  is  probably  the  complete  form  of  prolapse.  If 
seen  late,  especially  if  there  exists  an  irritable  sphincter 
which  is  likely  to  be  somewhat  contracted,  strangulation 
may  be  present  and  cause  the  patient  most  severe  pain.  In 
extreme  cases  of  complete  prolapse  part  of  the  peritoneum 
may  descend,  and  with  it  parts  of  the  intestines,  the  bladder 
or  an  ovary. 

The  third  variety  is  recognized  when  it  has  protruded 
externally,  by  observing  that  when  the  finger  is  passed  along 
the  external  surface  of  the  protrusion  it  will  not  stop  when 


64  DISEASES   OF   THE 

the  level  of  the  anus  is  reached,  but  will  continue  upwards 
into  the  body.  In  both  other  varieties  the  external  surface 
of  the  prolapsed  portion  will  be  found  continuous  with  the 
membrane  of  the  anus. 


TREATMENT. 

PARTIAL    PROLAPSE. 

If  hemorrhoids  exist,  as  is  often  the  case,  direct  treat- 
ment toward  their  removal  and  treat  the  prolapse  later. 
if  necessary.  In  children  it  is  not  uncommon  to  find  that 
they  have  one  or  two  attacks  of  this  trouble  and  are 
subsequently  free  from  it  entirely.  Before  applying"  the 
stronger  applications  necessary  in  adults  and  obstinate  cases. 
it  is  best  to  annoint  the  prolapsed  membrane  thoroughly  with 
an  astringent  ointment,  such  as  of  gallic  or  tannic  acid,  ace- 
tate of  lead  or  bismuth,  and  return  the  parts  into  the  body. 
Or,  simple  reduction  and  an  injection  of  half  an  ounce  of  the 
Ulcer  Specific  mentioned  under  the  treatment  of  rectal  ulcer, 
immediately  afterward.  The  bowels  should  be  kept  under 
restraint  for  a  few  days  by  means  of  astringents  or  opium, 
and  the  first  movement  secured  by  means  of  an  enema. 

"When  more  radical  measures  are  necessary  Carbolic 
Acid  is  perhaps  the  safest  and  best  remedy,  used  by  injection. 

A  ten  to  fifteen  per  cent,  solution  in  equal  parts  of  water 
and  glycerine  should  be  injected  at  two  or  three  places,  about 
half  an  inch  above  the  margin  of  the  anus,  about  the  location 
of  the  internal  sphincter,  to  the  edge  of  which  the  adhesions 
are  intended  to  attach  the  mucous  membrane.  Eive  to  eight 
minims  should  be  injected  at  each  spot,  and  care  must  be 
exercised  so  as  to  deposit  the  fluid  just  beneath  the  mucous 
membrane,  into  the  sub-mucous  space,  the  object  being  to 
excite  sufficient  inflammatory  action  to  cause  an  exudation 
of  plastic  serum,  to  produce  adhesions  between  the  mucous 
membrane  and  the  muscular  coats. 


RECTUM    AND    ANUS.  65 

The  following  formula  may  be  used  for  injection: 

^     Acid  Carbolic fl.  3  j. 

Glycerine    fl.  3  iv. 

Aqua    q.  s.  ad  fl.  §  j. 

Mix. 

Ergotin  has  been  recommended  for  these  injections,  but  its 
use  is  more  liable  to  be  followed  by  abscesses  than  that  of 
carbolic  acid.  The  following  ointment  is  an  excellent  one 
for  use  in  simple  prolapse,  or  after  injections. 

"B     Ext.  Ergot 3  ij. 

Acid  Boracic 3  ij. 

Ext.    Conium gr.  xv. 

Iron  Subsulph gr.  xl. 

Cocaine  Muriate gr.  viij. 

Vaseline    5  j. 

Mix.  Apply  into  rectum  after  reduction  of  prolapse, 
or  on  the  prolapsed  portion  before  reduction. 

Mason  recommends  the  following:  "Apply  cocaine  to 
the  protruded  mass  and  then  make  from  four  to  six  stripes 
along  the  long  axis  of  the  prolapse  with  fuming  nitric  acid. 
After  this  has  been  done,  oil  the  parts  well  and  replace  the 
prolapsed  portion.  Do  not  allow  a  bowel  movement  for  four 
days  and  then  only  in  the  recumbent  position  and  as  a  result 
of  an  injection  of  oil  or  flaxseed  solution.  This  operation 
is  painless,  safe,  easy  to  perform  and  will  cure  nearly  every 
case." 

COMPLETE    PROLAPSE. 

Treatment  for  this  condition  demands  an  examination 
as  to  its  cause.  It  may  be  due  to  a  relaxed  sphincter  which 
allows  the  lower  portion  of  the  rectum  to  descend.    In  these 


66  DISEASES   OF   THE 

cases  a  shortening  of  the  sphincter  by  contraction  is  indi- 
cated. This  is  usually  accomplished  by  means  of  the  actual 
cautery  and  necessitates  quite  an  extensive  and  elaborate 
preparation  not  generally  at  the  command  of  the  general 
practitioner.  This  also  applies  to  the  treatment  of  a  swollen, 
engorged  or  hypertrophied  condition  of  the  protruded  mass, 
for  which  the  best  treatment  is  excision  of  sufficient  of  the 
enlarged  portion  to  relieve  the  tendency  toward  protrusion. 
Contraction  of  these  parts  by  the  actual  cautery  is  also 
practiced  by  some  operators,  as  is  also  the  knife  in  operations 
for  contracting  the  sphincter. 

The  third  variety,  or  invagination,  is  usually  not  seen 
until  considerable  engorgement  and  perhaps  strangulation 
has  taken  place  and  reduction  is  impossible.  In  these  cases 
secure  a  good  surgeon  without  delay  as  it  is  a  formidable 
condition  and  one  that  requires  all  the  surgical  skill  of  the 
best  operators. 


Rectal  Polypus. 


Polypi  may  occur  in  the  rectum,  arising  as  they  do  from 
mucous  membrane,  wherever  located.  The  varieties  are 
similar  to  those  which  are  found  in  the  nose,  and  their 
removal  may  be  accomplished  in  the  same  manner.  The 
subject  is  mentioned  however  for  the  purpose  of  referring 
to  their  removal  by  the  injection  method,  in  a  similar  man- 
ner as  hemorrhoids.  They  can  be  distinguished  from  piles 
by  their  color,  being  of  a  pinkish  tint  and  bleeding  easily 
when  of  the  mucous  variety.  Any  mucous  polypus  can  be 
permanently  removed  by  injecting  it  in  a  similar  manner  as 
hemorrhoids,  but  when  the  tumor  is  hard  and  fibrous,  its 
removal  is  best  accomplished  by  the  snare.  If  polypi  are 
mistaken  for  hemorrhoids,  as  they  frequently  are,  and  treated 
as  such,  no  harm  will  result,  but  their  removal  perfectly 
accomplished. 


RECTUM    AND    ANUS.  67 


Reflex  Irritation  Due  to   Rectal 
Diseases. 

Rectal  diseases  are  a  prolific  source  of  all  manner  of 
abnormal  conditions  and  especially  of  peculiar  nervous  mani- 
festations, due  to  what  is  termed  reflex  irritation. 

The  generous  nervous  endowment  of  the  lower  end  of 
the  rectum  is  responsible  for  these  conditions.  At  the  verge 
of  the  anus  the  sensory  nerves  are  most  abundant,  which 
explains  the  extremely  sensitive  condition  of  this  part; 
while  at  a  distance  of  two  or  three  inches  above  the  anus  the 
sympathetic  nerves  predominate.  This  accounts  for  the 
difficulty  of  locating  the  cause  of  many  reflexes,  should  the 
lesion  be  located  in  the  portion  of  the  rectum  where  the 
sensory  nerves  are  not  so  prominent,  and  where  the  sensi- 
bility is  not  sufficient  to  enable  the  patient  to  locate  the 
trouble. 

Prof.  Pratt  has  said :  "In  all  pathological  conditions, 
surgical  or  medical,  which  linger  persistently  in  spite  of  all 
efforts  at  removal,  from  the  delicate  derangements  of  the 
brain  substance  that  induce  insanity  and  the  various  forms 
of  neurasthenia,  to  the  great  variety  of  morbid  changes 
repeatedly  found  in  the  coarser  structures  of  the  body,  there 
will  invariably  be  found  more  or  less  irritation  of  the  rectum, 
or  the  orifices  of  the  sexual  system,  or  both." 

Orificial  surgeons  are  often  accused  of  attributing  too 
much  to  reflex  irritation,  yet  it  is  true  that  much  that  should 
be  recognized  by  medical  practitioners  is  too  frequently  over- 
looked. 

Among  the  disorders  which  may  be  caused  by  rectal 
irritation,  and  toward  which  attention  should  be  directed 
should  they  prove  refractory,  may  be  mentioned,  abdominal 


68  DISEASES  OF  THE 

pains,  headache,  insomnia,  digestive  disturbances,  irritability 
of  the  bladder,  nervousness,  melancholia,  irritability,  sexual 
weakness,  nervous  prostration,  and  abnormal  conditions  of 
any  nature  that  indicate  a  perversion  of  the  nervous  equip- 
ment. 

The  local  lesions  that  are  liable  to  cause  either  or  several 
of  these  reflex  disturbances  are  generally  fissure  and  irritable 
ulcer,  undiscovered  fistula,  rectal  ulcer,  proctitis  and  a  form 
of  colitis  characterized  by  the  discharge  of  mucous  casts  of 
the  bowels,  tenesmus  and  considerable  pain. 

A  full  consideration  of  this  subject  would  require  more 
space  and  ability  than  are  at  my  disposal  and  all  I  can  hope 
to  do  is  to  direct  attention  to  the  factor  of  rectal  diseases  in 
the  production  of  the  obscure  pathological  conditions  so 
frequently  met  with,  and  which  so  persistently  resist  the 
action  of  symptomatic  treatment. 


RECTUM    AND    ANUS.  69 


Dilatation  of  the  Sphincters. 

Forcible  dilatation  of  the  sphincter  muscles  of  the  rectum 
is  undoubtedly  practiced  with  injudicious  frequency  by 
many  rectal  operators.  It  has  been  recommended  as  a 
curative  measure  for  practically  all  the  abnormal  conditions 
that  may  be  found  in  or  about  the  rectum  and  anus  and  on 
this  account,  when  practiced  by  its  ardent  but  unwise  advo- 
cates, has  become  the  cause  of  much  damage  and  untold 
suffering. 

That  there  are  certain  indications  in  which  dilatation  of 
the  sphincters  will  benefit,  none  will  deny,  but  when  prac- 
ticed as  a  routine  treatment  under  circumstances  in  which  it 
is  entirely  uncalled  for,  it  becomes  little  less  than  malprac- 
tice. 

It  is  indicated  in  all  conditions  where  spasmodic  muscu- 
lar contractions  occur,  regardless  of  what  other  disease  may 
or  may  not  be  present ;  in  fissure  it  is  unquestionably  of  ser- 
vice and  its  application  is  quite  general. 

In  any  condition  of  abnormal  tightness  of  the  sphincters, 
forcible  dilatation  will  afford  relief;  in  cases  of  obstinate  con- 
stipation when  the  movement  is  followed  by  a  feeling  of 
exhaustion  or  depression,  especially  in  persons  of  a  highly 
excitable  nervous  temperament ;  people  who  can  laugh  until 
they  cry  and  cry  until  they  are  a  wreck ;  especially  women, 
will  find  relief  after  a  thorough  dilatation.  Women  subject 
to  hysteria  are  frequent  sufferers  from  rectal  diseases,  and 
will  usually  be  benefited. 

As  is  well  known,  the  external  sphincter  is  the  last  of 
the  voluntary  muscles  to  undergo  relaxation  due  to  anesthe- 
sia ;  also  that  stretching  this  muscle  is  of  decided  value  in 


yo  DISEASES   0?  THE 

reviving  a  person  when  anesthetics  have  been  administered 
too  freely.    . 

This  is  also  the  case  when  persons  have  become  uncon- 
scious from  drowning,  action  of  narcotics,  heart  failure  and 
coma  from  various  causes. 

Before  attempting  to  dilate  the  sphincters  be  sure  that 
the  patient  is  thoroughly  anesthetized;  otherwise  spasmodic 
contractions  will  surely  occur.  Two  methods  are  used ;  the 
hands  of  the  operator  and  the  instrument  known  as  the 
rectal  dilator.  Both  methods  have  their  advocates  and  there 
are  good  reasons  for  recommending  either  one  of  them. 

Those  advocating  the  use  of  the  hand,  more  correctly 
the  thumbs  and  forefingers,  argue  that  as  the  muscles  are 
gradually  dilated  the  slight  yielding  sensation  can  be  felt 
and  used  as  a  guide  and  thus  too  great  a  degree  of  dilatation 
avoided.  On  the  other  hand,  advocates  of  the  rectal  dilator 
argue  that  by  the  use  of  the  instrument  the  degree  of  dilata- 
tion is  always  evident,  subject  to  measure  by  the  foot  rule, and 
the  limit  of  the  instrument  will  always  be  a  silent  witness  in 
the  instance  of  suits  for  malpractice  which  are  liable  to  fol- 
low any  sort  of  medical  or  surgical  treatment.  In  the  light 
of  legal  difficulties  the  operator  who  trusts  to  his  senses  and 
stops  the  stretching  when  he  considers  that  sufficient  force 
has  been  expended,  would  undoubtedly  be  somewhat  eclipsed 
by  the  mute  steel  witness  of  the  advocate  of  the  instrumental 
dilator.  This  line  of  argument  has  but  recently  been  pre- 
sented to  me,  and  I  deem  it  of  sufficient  value  to  give  it  space 
here. 

Perfect  anesthesia  having  been  induced  insert  the 
thumbs  of  both  hands  or  the  thumb  of  one  hand  and  the  first 
and  second  fingers  of  the  other  into  the  anus,  and  gradually 
yet  forcibly  produce  complete  relaxation  and  paralyzation 
of  the  muscles.  Care  must  be  taken  not  to  rupture  the  exter- 
nal sphincter,  an  accident  that  is  liable  to  occur  when  the 
force  used  is  too  great  or  too  rapid.  The  appearance  of 
the  mucous  membrane  protruding  from  the  anus  will  indicate 
sufficient  manipulation. 


RECTUM    AND    ANUS.  7 1 

Kneading  the  external'  sphincter  and  the  use  of  the 
graduated  hard  rubber  dilators  will  aid  in  overcoming  the 
resistance  and  lessen  the  liability  of  rupturing  the  muscle. 
In  women  the  rectum  is  capable  of  greater  dilatation  and  it 
should  be  borne  in  mind  that  their  support  anteriorly  is  less 
tense  and  durable  than  in  the  male. 

When  the  expanding  dilator  is  used  for  forcible  dilata- 
tion the  usual  preliminaries  are  observed  and  the  instrument 
introduced.  By  the  use  of  the  set  screw  gradual  expansion 
of  the  blades  is  obtained  until  the  desired  degree  of  dilatation 
is  reached. 

Any  of  the  expanding  dilators  will  be  found  applicable 
for  this  treatment,  yet  none  of  them  are  better  than  the 
regular  Pratt  sigmoid  speculum. 

In  order  to  avoid  the  usual  defecation  due  to  anesthesia 
as  well  as  dilatation,  see  that  the  bowels  are  thoroughly 
evacuated  by  a  flushing  half  an  hour  previous  to  the  opera- 
tion. 

For  treatment  of  fissure  by  dilatation  of  the  sphincters., 
see  under  Fissure. 

RECTAL  DILATATION  WITHOUT  ANESTHESIA. 

From  an  article  in  the  Medical  World,  by  William  L. 
Dickinson,  M.  D.,  Professor  of  Rectal  Diseases,  Saginaw 
Valley  Medical  College,  Saginaw,  Mich. 

"A  patient  comes  to  us,  and  having  made  an  examination 
we  inform  him  that  he  can  be  cured  provided  he  is  willing 
to  have  an  operation,  and  that  it  will  be  necessary  for  him  to 
take  an  anesthetic.  Reluctantly  he  consents  to  our  proposi- 
tion and  returns  home,  with  the  understanding  that  the 
operation  is  to  be  performed  as  soon  as  he  can  be  prepared 
for  it.  But  having  talked  with  friends,  he  decides  not  to  take 
the  chloroform  and  calls  us  up  by  telephone  to  inform  us 
that  he  has  changed  his  mind  and  will  not  have  the  operation 
just  at  present,  as  he  seems  to  feel  some  better.  In  a  few 
days  we  learn  that  the  patient  has  gone  to  another  doctor, 


72  DISEASES   OF  THE 

a,nd  that  the  other  doctor  has  promised  to  do  what  he  can 
for  him,  without  the  use  of  chloroform,  and  we  also  know 
that  if  the  patient  gets  any  benefit  whatever  from  the  treat- 
ment, that  his  influence  will  always  be  in  favor  of  the  doctor 
who  did  not  insist  on  giving  chloroform.  We  may  know 
that  he  used  very  poor  judgment  and  was  very  foolish  not  to 
follow  our  advice  and  be  permanently  cured,  but  on  the  other 
hand,  he  may  know  that  he  feels  much  better  now,  and  as  he 
did  not  have  to  take  the  chloroform  he  will  not  worry  about 
what  may  occur  in  the  future. 

The  time  honored  treatment  of  anal  fissure  by  dilatation 
under  chloroform  anesthesia  was  both  effective  and  speedy; 
but  we  can  accomplish  the  same  results  in  a  little  longer 
time  by  painting  the  fissure  with  a  ten  per  cent,  solution  of 
cocaine  and  then  dilating  the  sphincters  with  Pratt's  rectal 
dilators,  commencing  with  the  smallest,  and  increasing  to  the 
largest  size  that  the  patient  can  stand  at  each  treatment.  By 
the  forcible  dilatation  of  the  sphincters  under  an  anesthetic 
we  can  usually  cure  our  patient  by  one  treatment,  whereas 
under  the  gradual  dilatation  method  it  may  require  two  or 
three  weeks  to  accomplish  the  same  result,  but  when  a  patient 
consults  us  and  we  explain  the  two  methods  to  him,  he 
nearly  always  chooses  the  longer  method  if  he  can  possibly 
spare  the  time  to  make  the  requisite  number  of  calls  at  our 
office.  This  is  quite  natural,  as  every  one  shrinks  from  any- 
thing called  an  operation,  and  readily  takes  up  the  treatment 
that  is  nearly  painless.  It  is  well  to  paint  the  fissure  with  a 
ten  per  cent,  solution  of  nitrate  of  silver  after  the  dilatation. 
I  instruct  the  patient  to  return  in  three  days  for  another 
treatment,  and  to  apply  to  the  fissure,  twice  daily,  after  bath- 
ing with  hot  water,  and  ointment  composed  of 

Orthoform    grs.  xx. 

Ichthyol    5  i j . 

Lanolin §  j . 

Mix. 

Many  persons  who  are  now  great  sufferers  from  the 
common  diseases  of  the  rectum,  would  gladly  have  an  opera- 


RECTUM    AND    ANUS. 


73 


tion  for  their  relief  if  we  could  only  assure  them  that  they 
could  be  cured,  and  without  the  necessity  of  losing  conscious- 
ness. We  would  also  make  more  financially,  and  keep  many 
a  patient  from  going  to  some  man  who  perhaps  knows  little 
or  nothing  about  the  case,  but  does  have  a  far  better  knowl- 
edge of  human  nature  than  we,  and  also  understands  the 
business  side  of  the  profession. 

I  consider  it  a  duty  we  owe  to  our  patients  and  also  to 
ourselves,  to  do  all  in  our  power  to  keep  them  from  going  to 
the  irregular  practitioner,  for  as  regular,  educated  physi- 
cians, we  ought  to  be  able  to  cope  with  all  diseases  of  the 
rectum  in  an  intelligent  manner,  and  thus  give  entire  satis- 
faction to  our  patients." 


GRADUATED 

RECTAI. 

DILATORS, 
AND 
PRATT'S 

SIGMOID 
SPECULUM 
AND 

DILATOR. 


lOCHEB  &  SON.   01 


DISEASES  OF  THE 


Diseases  of  the  Anus. 

Pruritus  Ani. 

Obstinate  itching  of  the  anus  is  one  of  the  most  torturing' 
conditions  imaginable.  Patients  frequently  consult  the 
physician  with  a  statement  that  they  have  itching  piles,  but 
on  examination,  hemorrhoids  are  usually  found  absent, 
unless  possibly  external  tabs  which  have  become  inflamed 
and  oedematous.  Pruritus  may,  however,  accompany  almost 
every  disease  of  the  rectum,  and  while  perhaps  technically 
not  a  disease,  but  a  symptom,  it  frequently  causes  more 
annoyance  and  acute  torture  than  many  of  the  more  serious 
diseases.  Physicians  as  a  class,  excepting  only  those  who 
have  made  the  study  and  treatment  of  rectal  diseases  a 
specialty,  do  not  usually  credit  this  condition  with  the 
importance  it  deserves,  consider  it  a  trivial  complaint  easily 
relieved,  prescribe  an  ointment  or  a  wash,  and  because  the 
patient,  who  has  probably  consulted  some  other  physician, 
does  not  return,  imagine  he  has  been  cured. 

If  many  physicians  have  underestimated  this  condition, 
Dr.  Hoyt,  of  New  York,  cannot  be  accused  of  committing 
this  error,  as  the  following,  quoted  from  his  contributions 
to  the  literature  on  the  subject,  will  prove: 

"With  what  anguish  its  unhappy  victims  battle  through 
innumerable  sleepless  nights,  fighting  this  demon  of  so-called 
local  epilepsy,  with  its  long  array  of  itching,  burning,  exud- 
ing, corroding,  exhausting  and  blaspheming  characteristics, 
as  though  they  had  been  brewed  by  the  chemistry  of  hell ! 
The  whole  organization  becomes  a  chaotic  discord,  the  dis- 
position is  cruelly  warped,  the  countenance  shows  a  sad 
picture  of  living  woe.  the  carriage  is  nearly  lost  to  all  laws 
of  equilibrium,  and  the  complete  being  merges  into  a  throb- 
bing phantom  of  despair,  trembling  on  the  very  threshold 
of  idolized  suicide. 


RECTUM    AND    ANUS.  75 

"Of  course  I  speak  of  the  most  aggravated  cases, 
instances  that  seldom  occur  within  the  experience  of  general 
practitioners.  Wherefore  then  these  phenomena?  What  is 
the  mighty  influence  that  yields  so  much  distress  ? 

"The  meagre  literature  upon  the  subject  hobbles  upon  the 
crutches  of  hypothetical  inferences,  telling  you  perhaps  it  is 
capillary  congestion,  or  chronic  proctitis,  or  neurotic  hyper- 
aesthesia,  or  eczema,  or  malaria,  suggesting  a  panoramic 
array  of  remedial  agencies,  all  unsatisfactory,  thereby  con- 
fessing to  a  sad  condition  of  helpless  empiricism." 

The  paroxysms  of  itching  usually  become  more  acute 
after  the  patient  has  retired  for  the  night,  the  warmth  of  the 
bed  seeming  to  increase  the  moisture  of  the  parts,  although  the 
itching  may  continue  more  or  less  during  the  day.  When 
the  disease  has  existed  for  some  time  the  skin  about  the 
anus  becomes  thickened  and  somewhat  puckered,  the  folds 
numbering  as  many  as  six  or  seven  radiating  from  the  anus, 
and  which  on  separating  reveal  crevices  of  varying  depths, 
containing  a  moist  secretion. 

The  cause  of  this  condition  has  been  variously  ascribed 
to  parasites,  seat  worms,  acidity  of  the  alimentary  tract,  uric 
acid,  proctitis,  neurotic  conditions,  etc. 


TREATMENT. 

Constitutionally,  if  acidity  of  the  alimentary  tract  exists, 
or  an  excess  of  uric  acid,  the  proper  remedies  must  be  pre- 
scribed to  overcome  these  conditions. 

Potassium  bicarbonate,  sodium  hyposulphite  and  salicyl- 
ate are  indicated  in  the  former  condition,  and  lithia,  acetate 
of  potassium  and  alkaline  waters  in  the  latter. 

Locally  the  use  of  sodium  hyposulphite,  two  ounces  to  a 
pint  of  water,  applied  by  means  of  wet  cloths  is  often  of 
service.  If  seat  worms  are  present  an  injection  of  decoction 
of  quassia  will  dislodge  them  and  give  ease  to  the  patient,  but 
in   my  opinion   true  pruritus   ani   is  never  caused   by   seat 


7'J  DISEASES  OF  THE 

worms.  They  may  and  do  cause  itching,  but  not  the  charac- 
teristic condition  usually  noticed.  The  theory  of  microscopi- 
cal parasites  of  either  animal  or  vegetable  origin  is  more 
tenable  from  the  fact  that  anti-parasitic  remedies  very  fre- 
quently give  better  results  than  any  other  treatment. 

This  theory  is  endorsed  by  Hoyt,  who  recommends  the 
use  of  Black  Wash  (Calomel  and  Lime  Water),  three  times 
a  day,  applied  to  the  anus  immediately  after  bathing  the  parts 
with  water  as  hot  as  can  be  borne.  At  certain  points  or 
patches  where  this  remedy  fails  to  act  he  applies  Ung. 
Hydrargyri. 

For  vegetable  parasites  sulphurous  acid  is  an  effective 
remedy.  It  may  be  used  in  fifty  per  cent,  or  stronger 
solution.  When  used  pure  its  action  is  quite  severe,  but 
exterminates  the  parasites.  Several  applications  of  a  fifty 
to  sixty-five  per  cent,  solution  are  usually  preferable  to  one 
of  full  strength. 

Citrine  ointment,  carbolic  acid,  ammoniated  mercury  and 
sulphur  are  among  the  most  highly  recommended  remedies. 
I  recently  cured  a  case  by  two  applications  of  a  seventy-five 
per  cent,  solution  of  carbolic  acid  into  the  crevices  between 
the  folds  of  the  skin,  followed  by  the  usual  application  of 
dilute  alcohol. 

The  floors  of  these  crevices  had  all  the  appearance  of 
mucous  membrane,  from  their  long  exclusion  from  air,  and 
secreted  a  moisture  that  was  present  in  considerable  quantity. 
Mason  recommends  carbolic  acid  applications  to  the  skin, 
using  it  in  ninety-five  per  cent,  solution.  After  either  of 
these  applications  the  epidermis  will  peel  off  and  leave  a  new 
surface  which  may  require  a  soothing  dressing.  Several 
applications,  made  a  few  weeks  apart,  may  be  necessary. 

If  the  skin  has  a  very  harsh  and  dry  appearance,  a  satu- 
rated solution  of  nitrate  of  silver  should  be  painted  about  the 
anus  and  for  a  distance  of  several  inches  outward.  This 
will  stimulate  the  skin  and  it  will  resume  a  healthy  appear- 
ance after  two  or  three  applications.  As  soon  as  this 
solution  has  dried,  apply  to  the  anus  and  surrounding  parts, 


RECTUM    AND    ANUS. 


71 


citrine  ointment,  full  strength.  (Ung.  Hydrarg.  Nitratis). 
Dress  with  cotton  and  bandage.  After  three  or  four  days 
rhe  applications  of  nitrate  of  silver  are  discontinued,  but  the 
ointment  should  be  used  for  several  weeks,  or  until  cured, 
if  the  usual  progress  is  made. 

Applications  of  hot  water  will  momentarily  increase  the 
itching,  but  after  that  there  will  be  considerable  relief. 

When  more  or  less  varicosity  of  the  hemorrhoidal  ves- 
sels exists,  the  following  compound  will  be  of  service. 

3     Fl.  Ext.  Witch-hazel fl.  5  ij 

Fl.  Ext.  Ergot fl.  =  ss. 

Fl.  Ext.  Hydrastis fl.  5  ss. 

Tr.  Benzoin  Comp fl.  5  ss. 

Carbolized  Linseed  Oil  (5  per  cent.) .  fl.  3  ij 

Mix.     Shake  well  before  using. 

Sig.  Inject  one  to  three  drachms  into  the  cavitv  of  the 
rectum,  once  a  day. 

The  following  formulae  will  be  found  useful,  as  indi- 
cated. 

1^     Acid   Carbolic gtt.  xx. 

Sulphur    5  iij. 

Citrine    Ointment o  ss. 

Lanoline  or  Simple  Cerate 5  ss. 

Mix. 


Ammoniated  Mercury  is  perhaps  as  useful  a  remedy  as 
is  at  our  command.  The  following  ointment  has  served  me 
well. 

1^     Acid   Carbolic m,  xl. 

\mmoniated   Mercury 3  ij. 

Bismuth   Sub   Nitrate 3  ij. 

Vaseline    ^  ij. 

Mix. 


7^  DISEASES   0E  THE 

Calomel,  in  ointments  is  a  remedy  that  frequently  gives 
good  results,  although  treatment  that  cures  some  cases  will 
totally  fail  in  others. 

B      Calomel    gr.  lxxx. 

Benz.   Lard §  j. 

Mix. 


lent. 


]$     Acid  Carbolic gtt.  xx. 

Calomel    .  .  : 5  j. 

Balsam  Peru 3  iss. 

Lanoline    §  j. 

Mix. 


I£      Acid    Salicylic gr.  xv. 

Oil  of  Cade 3  j. 

Ung.    Zinc    Oxide §  j. 

Mix. 

For  the  itching  of  external  piles,  the  following  is  excel- 

1$     Acid    Tannic 5  ss. 

Powd.  Camphor gr.  xx. 

Powd.  Alum gr.  x. 

Powd.   Opium gr.  v. 

Acid    Carbolic TTL  x. 

Vaseline    %  j. 

Mix.     Apply  three  times  daily. 


RECTUM    AND    ANUS.  79 

Tar  ointment,  prepared  as  follows,  is  highly  recom- 
mended : 

.1$     Fresh  Tar g  vii j . 

Glycerine   g  xvj . 

(by  weight.) 

Starch    3  vj . 

Mix.  Rub  the  starch  with  the  glycerine  and  mix  with 
the  tar.  Put  on  hot  stove  and  stir  until  brought  to  the 
boiling  point,  then  remove  and  stir  until  cold.  Apply  on 
muslin  and  keep  in  place  with  a  T  bandage. 


T>     Acid  Carbolic 5  ij . 

Acid  Salicylic 3  iss. 

Sodium  Biborate 3  j. 

Glycerine §  j . 

Mix.     Sig.     Apply  as  necessary. 


A  good  formula. 

I>     Citrine  Ointment, 

Resin   Cerate aa  p.  c. 

Mix.     Wash  anus  with  soap  and  water  and  apply  lightly 
once  or  twice  a  day,  rubbing  in  well. 


I£      Campho-phenique    fl.  3  j. 

Losophan   gr.  xx. 

Petrolatum    "%  j . 

Mix.     Apply  night  and  morning. 


80  DISEASES  OF  THE 

Eczema  of  the  Anus. 

Eczema  is  frequently  met  with,  and  is  one  of  the  com- 
mon causes  of  irritation  of  the  anus.  It  is  caused  by  lack  of 
cleanliness  after  defecation,  constipation,  the  passage  of 
irritating  mucus,  or  discharge  from  a  fistula.  Eczema  fre- 
quently extends  backward  toward  the  coccyx  and  sacrum 
for  three  or  four  inches,  causing  much  discomfort.  It 
usually  occurs  in  persons  whose  general  health  is  not  good. 
When  the  surface  is  inflamed  and  cracked,  the  following  is 
a  good  remedy: 

I>      Powd.  Zinc  Oxide gr.  lx. 

Camphor  Liniment fl.  3  j. 

Lime  Liniment fl.  3  vj. 

Mix.  Clean  parts  and  apply  olive  oil  and  wipe  dry  with 
wool,  and  apply  this  preparation,  rubbing  it  in  well.  Cover 
with  a  layer  of  dry  cotton  and  bandage.  When  the  surface 
has  become  dry,  apply  the  following  powder: 

1$     Powd.  Zinc  Oxide gr.  lx. 

Powd.  Gum  Camphor gr.  lx. 

Powd.  Corn  Starch o  j- 

Mix. 


The  following  lotion  is  also  valuable,  especially  when  the 
skin  is  oedematous: 

fy     Liq.  Plumb.  Subacetate fl.  g  ss. 

Alcohol   fl.  5  j- 

Glycerine    fl-  5  j- 

Rose   Water fl.  o  xij- 

Mix.  Apply  on  wet  cloths,  continually  until  the  oedema 
has  disappeared. 

The  usual  treatment  for  eczema  in  other  locations  may  be 
employed  in  eczema  of  the  anus.  Cleanliness  alone  will  do 
much  toward  the  cure. 


RECTUM    AND    ANUS.  8 1 


Cocaine  Solutions  for  Rectal  Work. 

The  use  of  cocaine  has  been  somewhat  restricted  on 
account  of  the  fear  of  absorption  into  the  circulation  and  the 
resulting  toxical  effects. 

This  fear,  while  to  a  certain  extent  warranted,  is  carried 
coo  far  by  many,  as  the  dangers  attending  the  use  of  cocaine 
are  more  imaginary  than  real.  Toxical  effects  are  produced 
in  but  a  small  percentage  of  cases,  and  not  all  of  them  are 
by  any  means  alarming. 

For  local  applications  it  is  useless  to  attempt  to  produce 
any  appreciable  effect  short  of  a  fifteen  to  twenty  per  cent, 
solution,  while  for  injecting  into  the  tissues  a  four  to  eight 
per  cent,  solution  will  suffice. 

I  am  becoming  somewhat  more  partial  to  weaker  solu- 
tions for  injection,  not  on  account  of  the  danger  of  stronger 
solutions,  but  in  order  to  obtain  the  benefit  of  the  more 
bulky  injections.  Filling  the  tissues  full  of  water  alone  will 
render  minor  operations,  where  but  a  single  thrust  or  cut  is 
necessary,  practically  painless. 

For  the  prevention  of  toxical  effects,  it  is  suggested  that 
carbolic  acid  be  added  to  cocaine  solutions.  In  addition  to 
preventing  absorption,  this  mixture  keeps  better  than 
cocaine  alone,  its  anesthetic  action  is  increased  and  there  is 
no  tendency  to  inflammatory  reaction  after  its  use.  I  never 
use  cocaine  solutions  without  the  addition  of  carbolic  acid. 
One  drop  of  pure  carbolic  acid  being  added  to  each  drachm 
of  solution. 

If  unfavorable  symptoms  should  occur,  notably  heart 
failure,  inhalations  of  nitrite  of  amyl,  will  antagonize  its 
action. 

The  Schleich  method  of  securing  anesthesia  with  but  a 
minimum  of  cocaine  is  very  well  adapted  to  rectal  work,  and 
can  be  recommended  for  all  minor  operations  such  as  the 
removal  of  cutaneous  tabs,  cutting  through  small  fistulae,  etc. 


82 


DISEASES   OF   THE 


The  formulae  of  these  solutions  follow.  Tablets  of  the 
various  strengths  are  supplied  by  the  majority  of  pharma- 
ceutical firms. 

STRONG. 

Cocaine  muriate gr.  iij. 

Morphia  muriate.  .  . gr.  2-5 

Sodium    chloride gr.  iij. 

Distilled    water,    sterilized fl.  5  iijss. 

M. 

NORMAL. 

Cocaine    muriate gr.  iss. 

Morphia  muriate gr.  2-5 

Sodium   chloride gr.  iij. 

Distilled    water,    sterilized fl.  §  iijss. 

M. 

WEAK. 

Cocaine  muriate gr.   1-6 

Morphia  muriate gr.  2-5 

Sodium   chloride gr.  ii j . 

Distilled    water,    sterilized fl.  §  iijss. 

M. 

The  normal  solution  is  the  one  generally  employed,  and 
of  this  three  ounces  may  be  used.  The  strong  solution  is 
used  when  the  tissues  are  actually  inflamed.  Of  this  one 
ounce  may  be  injected  during  one  operation.  The  weak 
solution  is  used  when  the  previous  injection  has  been  inade- 
quate and  further  anesthesia  is  desired  in  the  deeper  tissues. 
As  much  as  four  ounces  may  be  injected. 

METHOD  OF  INJECTION. 

Injection  is  rendered  painless  by  applying  cocaine,  or 
ether  spray,  at  the  site  of  puncture.  The  needle  is  intro- 
duced within  the  skin,  and  a  few  drops  of  solution  pressed 
out  so  that  the  skin  itself  is  distended  by  the  fluid,  which 
occasions  a  white  wheal.  Even  pressure  is  now  applied  until 
this  wheal  is  enlarged  to  the  size  of  a  penny.  The  needle  is 
then  withdrawn,  and  inserted  again  within  the  radius  of  the 


RECTUM    AND    ANUS.  83 

first  anesthetized  wheal,  and  this  process  is  continued  until 
the  line  of  incision  is  marked  out.  Finally,  when  the  skin 
is  anesthetized,  the  subcutaneous  and  deeper  tissues  are 
infiltrated.  In  operating  upon  inflamed  parts  the  infiltration 
is  commenced  in  the  surrounding  healthy  tissue,  and  wheal 
after  wheal  is  formed  until  the  region  to  be  operated  upon  is 
saturated,  which  is  to  be  known  by  the  disappearance  of  the 
inflamed  color  and  the  appearance  of  the  white  zone  of  infil- 
tration. 

Dr.  Schleich  claims  that  this  process  of  anesthesia  is 
absolutely  devoid  of  danger.  It  is  essential  that  sufficient 
fluid — preferably  warmed  to  8o°-ioo°  F. — be  employed  to 
render  the  tissue  tense.  Ice-bags  to  the  edematous  area  will 
enhance  the  anesthesia,  and  constriction  greatly  assists 
in  prolonging  it. 

COCAINE  AND  SUPRARENAL  EXTRACT. 

The  value  of  suprarenal  extract  as  a  hemostatic  and 
anesthetic  agent  is  now  generally  known.  In  combination 
with  cocaine  and  eucaine  as  in  the  following  formula  the 
combined  effects  of  the  three  drugs  are  obtained.  Five  to 
six  minims  injected  into  the  skin  or  part  to  be  operated  on, 
will  produce  sufficient  anesthetic  action  for  small  operations. 

Cocaine  muriate gr.  v. 

Beta-eucaine    gr.  v. 

Sodium  chloride gr.  x. 

Dried  suprarenal  gland gr.  xxx. 

Water    fl.  5  j. 

In  making  this  combination,  the  suprarenal  is  mixed 
with  the  water,  .the  eucaine  and  salt  are  added  after  filtration, 
and  last  of  all,  just  before  using,  the  necessary  quantity  of 
cocaine  is  added.  This  makes  a  1  per  cent,  solution  of  the 
cocaine  and  eucaine,  which  may  be  freely  used  in  the  mucous 
membrane  without  fear  of  poisoning. 


84 


RECTAL  INSTRUMENTS. 


INSTRUMENTS  FOR  RECTAL  WORK. 

The  illustrations  of  Rectal  Instruments  herein  shown  are 
from  electrotypes  kindly  furnished  by  Max  Wocher  &  Son, 
Cincinnati,  O. 


The  Albright  Rectal  Set. 


This  set  contains  one  medium  Brinkerhoff  rectal  specu- 
lum ;  one  rectal  dressing  or  polypus  forceps  ;  one  silver  probe ; 
one  suppositor  for  ointments ;  two  improved  syringes  with 
caps ;  one  pure  silver  probe-pointed  canula,  for  the  explora- 
tion and  injection  of  sinuses,  fistulae,  etc. ;  one  guarded  long- 
point  gold  pointed  needle,  for  injecting  hemorrhoids;  one 
ordinary  hypodermic  needle  and  four  metal  screw-top  bottles 
for  holding  ointments,  etc.    Fine  Morocco  case. 

Any  physician  not  already  equipped  with  a  set  of  rectal 
instruments,  cannot  do  better  than  to  purchase  one  of  these 
sets.    It  is  compact  and  complete  and  furnishes  the  principal 


RECTAL  INSTRUMENTS. 


85 


instruments  for  the  treatment  of  rectal  diseases.  Variations 
in  the  same  can  be  made  to  order.  Purchasers  of  rectal 
instruments,  especially  those  purchasing  the  Brinkerhoff 
speculum,  should  be  careful  to  see  that  the  slides  in  them  are 
carefully  made,  as  I  have  found  by  experience  that  certain 
manufacturers  who  list  this  instrument,  do  not  use  the 
customary  care  in  making  their  goods,  and  turn  out  Brinker- 
hoff speculums  that  are  absolutely  worthless.  Messrs.  Wocher 
and  Son,  have  arranged  this  case  for  me,  with  the  Brinker- 
hoff speculum,  and  I  am  pleased  to  state  that  their  products 
are  very  accurate  in  mechanical  construction,  the  slides  of  the 
speculums,  both  the  Brinkerhoff  and  O'Neil,  are  well  made, 
and  the  instruments  eive  excellent  satisfaction. 


\ 


SON,   OIN..  O 


Hemorrhoidal  Syringe  and  Canula  Set. 


This  case  contains  a  solid  barrel  syringe,  with  cap, 
holding  thirty-five  minims ;  one  pure  silver  probe-pointed 
canula  for  the  exploration  and  injection  of  sinuses,  fistulae, 
etc. ;  one  ordinary  hypodermic  needle  and  one  long-point, 
gold  pointed  needle  for  the  injection  of  hemorrhoids,  having 
a  slide  cover  with  set  screw  by  means  of  which  the  distance 
the  needle  is  inserted  can  be  resrulated.     Fine  Morocco  case. 


86 


RECTAL  INSTRUMENTS. 


NEEDLE   AND    CANULA. 


This  illustration  shows  the  guarded  needle,  with  gol 
point  and  the  flexible  probe  canula,  made  of  pure  silver. 


%M*ss&sfe. 


Portable  Electric  Light  Outfit. 


The  accompanying  illustration  shows  a  portable  electric 
light  outfit  that  is  convenient  and  useful  when  examinations 
are  to  be  made  on  cloudy  days,  at  night,  or  whenever  sun- 
light is  not  available.  It  has  a  universal  attachment  for  con- 
necting with  either  rectal,  vaginal  or  nasal  speculum,  with 
lamp ;  a  tongue  depressor  and  otoscope,  both  with  light 
attachments,  and  a  diagnostic  lamp. 

The  battery  has  four  cells  and  is  quite  durable. 


CONSTIPATION.  87 


Constipation. 


Constipation  has  been  aptly  termed  "the  disease  of 
civilization."  This  is  significant  but  not  correct,  as  consti- 
pation is  not  a  disease  per  se,  but  rather  a  symptom  of  a 
disease,  or  an  evidence  of  an  abnormal  condition  or  imperfect 
functional  action  of  some  part  of  the  alimentary  canal. 

The  lesson  taught  by  the  small  boy,  who  when  asked 
by  his  teacher  to  name  the  most  important  canal  in  the  world, 
replied  "the  alimentary,"  might  well  be  impressed  upon  our 
memory  and  our  actions  governed  accordingly. 

Dr.  Jamison,  of  New  York,  in  his  work  on  Intestinal 
Diseases,  says,  "As  I  have  already  said,  the  chief  ill  of 
'civilized'  people  is  Proctitis ;  the  chief  symptom  of  proctitis 
is  constipation ;  the  chief  symptom  of  constipation  is  dyspep- 
sia, the  chief  symptom  of  dyspepsia  is  neurasthenia,  and  so 
on  and  so  on — all  of  them  the  outcome  of  imperfect  elimina- 
tion of  morbid  matter  from  the  intestinal  canal." 

In  a  normal  state,  the  rectum  is  empty ;  not  a  receptacle 
for  feces,  but  a  conduit  during  the  act  of  defecation.  Should 
the  desire  for  evacuation  not  be  responded  to,  the  feces  will 
be  returned  into  the  sigmoid  cavity.  Frequent  repetitions  of 
this  common  occurrence  will  in  a  comparatively  short  time 
lead  to  inflammation  and  to  a  certain  extent  a  loss  of  normal 
power,  and  instead  of  the  feces  being  returned  into  the  sig- 
moid cavity,  will  distend  the  rectum  into  a  more  or  less 
roomy  pouch,  a  receptacle  for  the  fecal  matter  that  then 
becomes  an  irritant  foreign  body  and  a  cause  of  auto- 
toxemia. 

As  this  matter  is  allowed  to  accumulate,  its  liquid  and 
gaseous  portions  are  absorbed  and  the  resulting  hardened 
mass,  by  pressure  on  the  circulatory  system  obstructs  the 
flow  of  blood  to  and  from  the  parts,  causing  congestion, 
more  inflammation,  dilation  of  the  veins,  hemorrhoids,  etc. 


88  CONSTIPATION. 

Ever  since  1496,  when  Gatenaria,  an  Italian,  invented 
an  appliance  for  taking  an  enema,  the  harmful  effects  of 
intestinal  irritants,  powerful  cathartics  and  liver  stimulants, 
as  remedies  for  the  cure  of  constipation,  have  beeen  recog- 
nized. The  free  use  of  saline  cathartics  which  cause  an  addi- 
tional secretion  of  fluids  into  the  intestinal  canal  is  of  little 
more  value,  as  the  resultant  loss  of  fluids,  for  the  next  por- 
tion of  digestible  matter  can  only  result  in  continued  if  not 
greater  constipation. 

In  the  matter  of  intestinal  irrigation,  the  use  of  depura- 
tory  enemas  of  either  water  or  oil,  or  either  in  combination 
with  other  substances,  the  lay  public  has  probably  for  some 
time  occupied  a  position  in  advance  of  the  profession,  as  it 
is  a  fact  that  while  the  physician  but  seldom  recommends  a 
systematic  course  of  this  method  for  the  purpose  of  relieving 
constipation  and  curing  the  attendant  inflammation,  very 
many  of  the  more  intelligent  laity  practice  colonic  flushings 
and  general  depurant  procedures  with  scrupulous  regularity. 
Any  physician  who  has  observed  the  passing  of  the  chronic 
dyspeptic,  neurasthenic,  phlegmatic  and  hypochondriacal 
patient  and  the  evolution  of  a  normal,  healthy,  active  and 
care-free  person,  from  a  course  of  intestinal  irrigation  sys- 
tematically employed,  must  of  necessity  become  an  enthusi- 
astic advocate  of  the  method. 

In  many  cases  the  results  are  little  short  of  marvelous ; 
in  all  of  them  sufficient  benefit  is  derived  to  fully  justify  the 
practice. 

Irrigation  of  the  alimentary  canal  is  not  necessarily 
limited  to  the  introduction  of  water  and  solutions  into  it 
through  the  rectum,  but  a  great  deal  of  good  can  be  accom- 
plished by  the  regular  and  systematic  drinking  of  generous 
quantities  of  water.  This  will  insure  effective  irrigation  of 
the  assimilative  and  eliminative  organs ;  preserves  health 
when  present  and  assists  in  its  restoration  when  absent,  by 
restoring  activity  of  the  principal  organs  of  the  digestive 
svstem. 


CONSTIPATION.  89 

Very  few  realize  how  essential  water  is  to  digestion  and 
to  the  digestive  canal  after  its  function  is  completed.  There 
exists  a  great  natural  demand  for  water  to  carry  on  the 
normal  functions  of  the  system,  for  both  atmosphere  and  heat 
draw  moisture  from  the  body  and  a  considerable  amount  is 
utilized  in  this  manner. 

An  organism  composed  of  over  seventy-five  per  cent,  of 
water  requires  a  generous  supply  for  subsistence — a  supply 
equal  to  the  expenditure  of  vitality  involved  in  carrying  on 
the  numerous  functions  of  the  body  and  brain. 

The  following  may  be  followed  as  a  fair  schedule  for 
the  use  of  water  as  a  remedy ;  using  it  with  a  view  of  obtain- 
ing its  physiological  action. 

On  arising  in  the  morning  one  pint  of  water  should  be 
taken  to  cleanse  the  stomach  of  whatever  debris  remains 
from  the  previous  day's  food  and  for  its  invigorating  action. 
The  temperature  of  the  water  may  be  that  which  is  most 
agreeable,  but  should  not  be  ice-cold.  During  breakfast, 
which  should  follow  during  the  next  hour,  at  least  half  a  pint 
should  be  taken,  more  if  agreeable.  The  idea  that  liquids 
drunk  during  a  meal  weaken  and  impair  the  gastric  juice 
may  influence  some  against  this  practice,  yet  experience 
proves  that  there  is  really  no  ground  for  this  theory,  and  no 
objection  to  it.  The  water  rapidly  leaves  the  stomach  and 
does  not  in  the  least  interfere  with  proper  digestion.  About 
an  hour  before  the  noon  meal  a  half  to  one  pint  should  be 
drunk  and  during  the  meal  a  similar  quantity,  if  not  produc- 
tive of  uneasiness.  About  four  or  five  o'clock  in  the  after- 
noon half  to  one  pint  should  be  drunk  as  a  cleanser  before 
the  evening  meal,  during  the  ingestion  of  which  a  similar 
quantity  is  disposed  of.  Should  there  be  no  inconvenience 
from  a  full  bladder  during  the  night,  a  glass  or  two  will  be 
beneficial,  taken  before  retiring.  These  quantities  should  be 
taken  with  the  same  regularity  as  is  observed  in  taking 
medicine,  and  are  in  addition  to  the  water  required  for 
ciuenchinsr  anv  thirst  that  mav  occur  during-  the  intervals. 


90  CONSTIPATION. 

At  first  the  quantities  named  may  seem  excessive  to 
some  patients,  and  until  accustomed  to  the  great  change 
smaller  amounts  may  be  taken,  but  should  be  steadily 
increased  until  the  full  quantities  mentioned  can  be  taken 
without  inconvenience. 

It  is  a  singular  fact  that  constipated  people  drink  but 
little  water.  It  has  been  suggested  that  this  very  fact  is 
responsible  for  their  condition,  but  such  is  not  entirely  the 
case.  It  is,  however,  not  surprising  to  find  constipation  in 
people  who  drink  less  than  two  pints  of  fluids  daily,  nor  to 
note  the  great  change  and  general  improvement  that  takes 
place  after  beginning  a  systematic  course  of  water  treatment. 
It  is  not  always  best  to  inform  the  patient  that  water  is  the 
only  remedial  agent  needed,  as  by  so  doing  you  are  liable  to 
be  called  a  water  doctor,  or  a  water  crank,  and  your  patient 
will  soon  find  some  drug  doctor  who  will  heartily  agree  with 
him,  and  continue  the  drug  treatment  they  all  love  so  well. 

In  order  to  keep  your  patient  under  observation,  it  is 
well  to  prescribe  or  furnish  a  remedy  which  will  serve  as  an 
incentive  to  follow  the  treatment.  For  this  purpose  a  tonic 
or  other  remedy,  should  the  patient  be  in  need  of  it,  may  be 
given  at  the  hours  mentioned,  with  directions  to  follow  it 
always  with  the  water.  Should  no  actual  remedy  be  indi- 
cated a  placebo  will  answer  very  well. 

Persons  in  health  should  make  water  drinking  a  habit, 
as  eating,  exercising,  etc.  Regularity  and  system  is  as  essen- 
tial for  the  harmonious  working  of  the  vital  organs  as  it  is 
for  the  relations  of  the  departments  in  a  business.  Some 
training  is,  however,  necessary  in  most  cases,  and  what  is  at 
first  not  agreeable  will  in  a  short  time  become  so. 

Water  is  the  most  wholesome  of  all  drinks.  Wholesome 
in  the  German  expresses  a  thought  even  more  potent.  In 
English  we  define  the  word  as  "Tending  to  promote  health 
or  contributing  to  it,"  but  the  German  "Heilsam"  expresses 
even  more,  "Healing,  or  possessing  healing  properties."  It 
quickens  the  appetite,  aids  and  strengthens  digestion,  is  most 
effective  in  the  work  of  elimination,  prevents  clogging  and 


CONSTIPATION.  *         91 

removes  interstitial  deposits.     It  cleanses,  irrigates,  purifies 
and  invigorates. 

Diseases  caused  by  a  lack  of  irrigation  will  cause  an 
accumulation  or  congestion  of  the  contents  of  the  gastro- 
intestinal canal,  and  the  victim  of  slow  transit  complains  of 
indigeston,  biliousness,  flatulency,  uric  acid  symptoms,  etc. 
Dyspeptics  of  this  order  require  a  thorough  internal  bath 
from  above  and  from  below. 


ENEMAS. 
When  They  Should  be  Taken. 

To  re-establish  the  normal  physiological  relations  called 
health,  after  many  years  of  perverse  relations  and  disorderly 
practices,  obviously  requires  time  and  intelligent  attention 
to  the  prescribed  directions.  The  factors  that  militate  against 
the  removal  of  curable  diseases  are :  ( 1 )  The  neglect  of  a 
local  disorder  until  it  has  had  time  to  exhaust  the  general 
vitality  of  the  system. 

(2)  Inattention  on  the  part  of  the  patient  after  he  has 
obtained  temporary  or  partial  relief.  (3)  The  patient  arbi- 
trarily setting  his  own  time  limit  for  the  cure  of  the  disease. 
(4)  Wilful  disobedience  of  prescribed  directions.  (5) 
Inability  to  realize  the  importance  of  having  the  cause 
removed,  as  well  as  the  local  symptoms.     (Jamison). 

In  all  cases  of  proctitis  or  colitis,  with  the  many  attend- 
ant symptoms  and  ills,  no  better  means  for  relieving  and 
removing  these  undermining  disorders  can  be  adopted  than 
the  regular  practice,  twice  a  day,  of  intestinal  irrigation  by 
means  of  enemas  night  and  morning.  During  the  long  period 
of  relaxation  at  night,  the  functions  of  elimination  and  repair 
proceed  under  abnormal  conditions.  There  may  be  excessive 
fermentation  and  bacterial  putrefaction  which  generate 
poisonous  gases  that  are  absorbed  and  bring  about  the  condi- 
tion of  malaise  complained  of  on  arising  in  the  morning.  At 
this  time  a  small  enema  is  advisable  to  relieve  the  excessive 


92  CONSTIPATION. 

pressure  from  gases  and  feces.  Half  to  one  pint  of  water 
should  be  injected  and  expelled  at  once.  This  removal  of  the 
contents -of  the  rectum  and  perhaps  of  the  sigmoid  will  per- 
mit the  contents  of  the  ascending  and  transverse  colon  to 
pass  more  readily  toward  and  into  the  sigmoid  flexure,  and 
when  half  an  hour  or  more  has  passed,  it  is  time  for  the 
regular  and  complete  evacuation  of  the  bowels  by  the  inter- 
nal bath  or  flushing  of  the  colon. 

Before  retiring  another  small  enema  should  be  taken, 
and  at  once  expelled.  This  before-retiring  enema  will  often 
do  so  much  for  the  patient  that  it  will  be  soon  found  unnec- 
essary to  take  the  preliminary  morning  injection,  inasmuch 
as  fermentation  and  gas  are  no  longer  present. 

FLUSHING  THE  COLON. 

Flushing  the  colon  is  a  discovery  of  great  value, 
although  brought  to  notice  in  an  irregular  way,  and  has  a 
place  as  a  remedial  agent  with  which  every  physician  should 
become  familiar.  Various  devices  have  been  exploited  as 
ideal  instruments  for  the  correct  application  of  this  means, 
yet  no  special  apparatus  is  necessary,  not  even  the  long  and 
filthy  rubber  tube  which  is  known  as  the  colon  tube.  This 
article,  when  introduced  and  insinuated  into  and  through 
twelve  or  eighteen  inches  of  the  bowel  is  liable  to  cause  a 
great  deal  more  irritation  and  subsequent  inflammation  than 
is  compensated  for  by  the  benefit  derived  from  its  use.  An 
ordinary  fountain  syringe  with  a  capacity  of  one  gallon,  and 
the  ordinary  small  vaginal  tube  is  all  the  paraphernalia 
necessary,  and  is  preferable  to  the  bulb  syringe,  as  the  force 
is  entirely  that  of  gravity. 

The  water  used  for  colonic  flushings  should  be  moder- 
ately hot,  as  when  tepid  water  is  used  severe  cramps  are  liable 
to  follow.  The  position  of  the  body  for  flushing  the  colon 
may  be  either  the  genu-pectoral  or  flat  on  the  back  with  the 
hips  elevated,  both  feet  on  the  floor  so  that  an  additional 
elevation  of  the  hips  may  be  obtained  by  slight  exertion. 


CONSTIPATION.  93 

The  tube  should  be  introduced  into  the  rectum  beyond 
the  internal  sphincter,  the  flow  of  water  being  controlled  by 
the  stop  cock  supplied  with  fountain  syringes,  or  by  the  hand 
of  the  patient.  Should  the  desire  for  evacuation  become 
irresistible  after  a  small  quantity  of  water  has  been  injected, 
the  rectum  should  be  unloaded  and  a  second  or  third  attempt 
should  be  made.  Success  usually  follows  one  or  two  futile 
attempts.  The  quantity  of  water  necessary  to  produce  free 
evacuation  varies  in  different  individuals,  being  a  matter  of 
capacity,  but  averages  two  to  three  quarts.  After  the  proper 
amount  has  been  passed  into  the  bowel  the  patient  may 
retain  it  from  five  to  ten  minutes.  If  a  diuretic  action  is  also 
desired  it  may  be  retained  twenty  to  thirty  minutes.  When 
retained  half  an  hour  a  considerable  portion  of  the  water 
is  absorbed  and  immediate  and  copious  urination  is  not  infre- 
quent. In  these  cases  the  action  on  the  colon  is  largely  lost, 
as  only  a  portion  of  the  water  injected  is  passed  out  through 
the  rectum.  Water  alone,  or  the  addition  of  four  ounces  of 
glycerine  to  three  quarts  of  water,  is  all  that  should  ever  be 
used  for  this  purpose. 

Do  not  imagine  that  a  daily  movement  of  the  bowels 
precludes  impaction  of  the  colon.  The  daily  excreta  may  be 
twenty- four  to  forty-eight  hours  over  due.  Stools  black  or 
dark  green  with  a  foul  and  carrion-like  odor  always  indicate 
age,  and  flushing  is  indicated.  The  chief  symptoms  of  auto- 
toxemia  may  be  said  to  be  fermentation,  flatulency,  some- 
times to  such  an  extent  as  to  encroach  on  the  breathing  and 
cause  acceleration  of  the  heart  and  consequent  vertigo  and 
headache,  sallow  complexion,  furred  tongue,  foul  breath, 
muddy  sclerotics,  chloasmic  spots,  defects  of  vision,  malaise, 
especially  on  arising,  and  from  internal  pressure,  dropsical 
swelling  or  numbness  of  the  lower  extremities. 

Bear  this  in  mind  when  baffled  by  a  stubborn  headache, 
especially  of  the  recurrent  type  and  among  women. 

As  to  the  drug  treatment  in  these  disorders  it  is  but  just 
to  say  that  very  often  complications  or  conditions  exist,  the 
treatment  of  which  demand  certain  drugs.     In  our  quest  of 


94  CONSTIPATION. 

knowledge  and  the  holding  fast  to  that  which  is  good,  let  us 
not  forget  nor  forsake  the  remedies  that  have  been  found  of 
service  to  us.  I  have  never  been  able  to  see  any  advantage 
result  from  the  use  of  aloin  or  podophyllin  in  the  treatment 
of  patients  having  disease  of  the  intestinal  tract,  particularly 
hemorrhoids.  Undoubtedly  the  best  remedy  for  laxative 
effect  is  cascara  sagrada,  given  either  in  the  form  of  fluid 
extract,  aromatic  extract  or  the  dry  extract.  Its  action  is 
mild,  causes  no  griping  and  produces  a  generous  stool.  Com- 
bined with  senna  it  is  more  active,  yet  frequently  irritating 
when  disease  of  the  bowels  exists. 

Glycerine  is  well  suited  as  a  diluent,  aiding  the  cascara 
by  its  depletive  action.  In  atonic  conditions  strychnine  is  a 
valuable  remedy,  as  is  well  known. 

Abdominal  massage,  following  the  direction  of  the  colon 
is  of  frequent  benefit,  as  is  also  a  systematic  course  of  exer- 
cise. Diet  plays  no  small  part  in  the  action  of  the  bowels  and 
much  can  be  accomplished  if  the  patient  is  willing  to  pay 
attention  to  this  particular. 

Food  which  supplies  but  a  minimum  of  nourishment 
and  leaves  a  large  amount  of  residue  should  be  avoided. 
Regularity  of  meals  is  important,  as  is  in  fact  regularity  in 
all  things.  Food  known  to  have  laxative  properties,  such 
as  prunes,  fresh  fruits,  figs  or  dates  may  be  taken  in  proper 
quantities,  also  food  containing  large  proportions  of  liquids. 
The  various  soups,  broths,  bouillons,  etc.,  need  not  be  indi- 
vidually mentioned.  Cereals,  bran  bread,  the  new  breakfast 
foods  and  the  like  are  indicated,  the  coarse  particles  of  which 
are  said  to  cause  an  additional  amount  of  peristaltic  action. 


HERNIA.  95 

HERNIA. 

The  Protrusion  of  any  Viscus  from  its  Natural  Cavity, 
through  Normal  or  Artificial  Openings  in  the  Surrounding 
Structures. 


INGUINAL  HERNIA. 

A  Protrusion  of  the  Abdominal  Contents  through  the 
Abdominal  Parietes,  into  or  through  the  Inguinal  Canal. 


Treatment  op  Inguinal  Hernia  by  the 
Injection  Method. 

A  Thoroughly  Reliable,  Practically  Painless  and  Abso- 
lutely Safe  Treatment  for  a  Distressing  and  Dangerous 
Affection. 


Although  originated  by  a  physician  and  surgeon  who 
stood  at  the  very  pinnacle  of  the  profession,  the  treatment  of 
reducible  hernia  by  the  injection  method,  has,  until  within 
the  last  decade,  been  practically  lost  to  the  legitimate  practi- 
tioner. 

The  conception  and  practical  application  of  the  method 
of  treating  hernia  by  the  use  of  injections  of  irritating  sub- 
stances into  the  inguinal  canal,  with  a  view  of  exciting  a 
sufficient  degree  of  inflammation  therein  to  cause  a  closure 
thereof  by  the  formation  of  adhesions,  was  in  a  former  edition 
of  this  work  credited  to  Dr.  George  Heaton,  but  further 
investigations  and  researches  prove  conclusively  that  the 
honor  of  the  discovery  belongs  to  no  other  than  the  dis- 
tinguished Philadelphia  surgeon,  Prof.  Joseph  Pancoast, 
M.  D.,  whose  memory  is  revered  by  the  medical  profession  of 
the  world. 


96  HERNIA. 

In  his  "Treatise  upon  Operative  Surgery,"  published  in 
1844,  he  records  the  treatment  of  thirteen  cases  of  hernia  by 
this  method,  while  Surgeon  to  the  Philadelphia  Hospital,  in 
1836,  using  Lugol's  Solution  of  Iodine  or  Tr.  Cantharides. 

According  to  Dr.  Joseph  H.  Warren,  the  date  of  Dr. 
Heaton's  first  operation  was  1840.  He  first  practiced  his 
profession  in  Alton,  111.,  but  after  a  short  time  removed  to 
St.  Louis.  In  1842  he  located  in  Boston,  and  although  he 
had  previously  successfully  treated  hernia  by  this  method, 
it  was  in  the  latter  city  that  he  first  came  to  prominence,  not 
only  by  the  success  that  attended  his  work,  but  also  on 
account  of  a  controversy  between  himself  and  a  committee 
appointed  by  the  American  Medical  Association  to  investigate 
the  subject. 

Shortly  afterward  he  went  to  London  and  Paris,  where 
he  was  given  a  cordial  reception  and  was  invited  to  perform 
his  operation  in  various  hospitals.  Returning  from  Europe 
he  again  resumed  his  practice  in  Boston,  and  continued  his 
work  until  near  the  time  of  his  death,  in  July  1879. 

Dr.  Heaton,  although  not  the  originator  of  the  method, 
deserves  much  credit  for  taking  up  the  work  and  to  a  certain 
extent  perfecting  it. 

After  experimenting  with  the  remedies  used  by  Prof. 
Pancoast,  he  discarded  them  and  began  the  use  of  the  extract 
of  White  Oak  Bark,  and  compounds  of  which  it  was  the 
chief  ingredient. 

Dr.  Jos.  H.  Warren,  also  a  Boston  practitioner  and 
intimate  friend  of  Dr.  Heaton,  continued  the  work  after 
the  death  of  the  latter,  and  in  addition  to  devising  a  number 
of  special  instruments,  principally  syringes  and  needles,  made 
some  additions  to  the  Heaton  formula  which,  in  his  opinion, 
made  it  more  efficient  and  less  dangerous  ;  for  it  must  be 
remembered  that  although  many  remarkable  cures  were 
effected  in  the  practice  of  these  two  physicians,  their  method 
was  by  far  more  severe,  and  the  resulting  inflammation  con- 
siderably more  pronounced  than  at  the  present  stage  of  the 


HERNIA.  97 

treatment.  Their  custom  was  to  give  large  single  injections, 
thus  causing  an  intense  degree  of  inflammation,  and  to  keep 
the  patient  in  bed  for  a  period  of  two  weeks.  One  treatment 
was  often  sufficient  to  cure  the  hernia,  yet  not  infrequently 
was  it  necessary  to  repeat  the  injections  several  times. 

Under  such  circumstances  it  is  not  difficult  to  under- 
stand that  prospective  patients  soon  began  to  rate  this  opera- 
tion with  those  of  major  surgery,  and  considering  the  pain 
caused  by  the  introduction  of  the  heavy  spiral  needles  used, 
preferred  an  anesthetic  and  the  radical  operation  by  the  knife. 

After  reading  Warren  on  "Hernia"  and  treatment  by 
the  method  of  sub-cutaneous  injection,  as  he  called  it,  one 
cannot  fail  to  receive  the  impression  that  although  he  had 
performed  the  operation  many  times  and  cured  numerous 
persons,  he  was  constantly  in  dread  of  ill  effects.  This  is 
shown  by  his  hesitancy  in  urging  others  to  take  up  the  work, 
and  the  constant  references  to  the  necessity  of  extreme 
caution.  He  also  condemned  the  use  of  the  ordinary  sharp 
hypodermic  needle,  and  referred  to  the  liability  of  penetrat- 
ing the  epigastric  artery. 

The  success  attending  the  modern  methods  of  giving 
injections,  viz:  with  a  sharp  needle  plunged  through  the 
pubic  tissue,  and  the  utter  impossibility  of  injuring  any 
vessels  of  the  canal,  prove  that  his  fears  were  unfounded 
even  under  ordinary  precaution,  and  with  but  a  fair  knowl- 
edge of  the  subject.  Elsewhere  in  this  volume  explicit  yet 
simple  directions  are  given,  which  if  followed  render  the 
operation,  if  so  simple  a  procedure  can  be  so  termed,  entirely 
void  of  the  slightest  danger. 

Contemporary  with  Warren,  among  those  who  mani- 
fested interest  in  this  method  of  treating  inguinal  hernia. 
Drs.  Davenport,  Janney,  J.  Mason  Warren,  and  others  of 
more  or  less  prominence  might  be  mentioned. 

As  previously  stated,  notwithstanding  the  high  profes- 
sional standing  of  these  and  other  physicians,  the  method 
was  not  endorsed  by  the  profession  at  large  and  for  a  number 
of  years  little  or  nothing  was  heard  of  it.    The  unsatisfactory 


98  HERNIA. 

termination  of  the  conference  between  Dr.  Heaton  and  the 
committee  appointed  by  the  A.  M.  A.  to  investigate  the 
method,  due  chiefly  to  the  inclination  of  Dr.  Heaton  to  retain 
the  secret  he  claimed  to  have  discovered,  may  also  in  a 
measure  have  contributed  to  the  decline  of  interest  along 
this  line  of  work. 

Within  the  last  decade,  however,  this  method  has  been 
revived  and  has  received  the  attention  it  merits  at  the  hands 
of  intelligent  and  careful  practitioners,  until  it  to-day  occupies 
a  place  among  the  few  certainties  in  medical  or  surgical 
practice.  Much  of  the  opposition  that  is  found  against  this 
method  originates  in  a  similar  manner  to  that  existing  against 
other  well  known  and  reliable  forms  of  treatment  for  numer- 
ous diseases,  i.  e.,  its  use  by  irregular  practitioners.  It  is 
however  true,  and  I  believe  quite  generally  conceded 
that  this  class  of  practitioners  have  been  largely  responsible 
for  the  general  awakening  on  this  subject  that  is  apparent 
to  even  the  casual  reader  of  medical  literature. 

This  manifest  interest  in  the  subject,  now  entertained 
by  men  of  high  professional  and  unquestioned  ethical  stand- 
ing, is  now  rapidly  assuming  the  characteristics  of  a  boome- 
rang to  the  irregulars,  in  as  much  as  it  is  reclaiming  to  the 
general  practitioner  a  class  of  business  which  formerly  was 
almost  exclusively  in  the  hands  of  the  class  of  practitioners 
before  mentioned.  This  is  precisely  as  it  should  be,  as  the 
general  practitioner  who  will  give  the  subject  the  necessary 
attention  to  become  familiar  with  the  details  of  the  treatment, 
can  apply  the  same  with  the  same  degree  of  success  that 
attends  the  specialist  in  this  work,  and  bring  it  within  the 
reach  of  a  larger  number  of  unfortunate  sufferers. 

Prior  to  the  perfection  of  this  method  of  treating  hernia, 
neither  medical,  surgical  nor  mechanical  skill  could  produce 
anything  toward  the  alleviation  of  persons  thus  afflicted, 
beyond  an  uncertain  and  actually  dangerous  operation,  or 
a  more  or  less  uncomfortable  truss. 


HERNIA.  99 

Makers  of  trusses  frequently  claim  curative  action  for 
their  ware,  but  unless  in  very  small  or  recent  cases  these 
statements  are  not  supported  by  facts ;  facts  that  can  be 
confirmed  in  the  experience  of  any  practitioner.  That  the 
truss  has  proved  a  failure  as  a  curative  agent,  is  now  admit- 
ted by  practically  all  except  those  interested  in  their  sale. 
While  hitherto  it  has  been  the  only  resort  of  the  ruptured, 
the  continual  pressure  on  the  parts,  by  exciting  a  certain 
degree  of  inflammation  about  the  region  of  the  external  ring, 
frequently  causes  a  closing  of  this  opening,  leaving  an  in- 
complete hernia  behind  it ;  in  reality  a  more  complicated 
affair  than  at  its  first  appearance. 

The  principle  of  the  injection  method  is  the  same  as 
that  of  the  radical  cure  operation ;  that  of  closing  the  canal 
and  preventing  the  descent  of  the  bowel,  membranes,  or 
both,  but  it  possesses  the  advantage  over  the  former  method 
in  that  it  affords  perfect  safety,  freedom  from  pain,  no 
detention  from  business  or  labor,  fully  90  %  of  cures  in 
cases  to  which  it  is  adapted,  and  what  to  many  is  a  consoling 
assurance,  if  it  does  not  cure,  it  will  do  no  harm. 

When  it  is  remembered  that  competent  statisticians  have 
informed  us  that  the  number  of  persons  afflicted  with  either 
of  the  various  forms  of  hernia,  equal,  if  not  exceed  one-tenth 
of  the  male  population,  the  vast  amount  of  clinical  material 
that  is  allowed  to  drift  to  the  dealer  in  trusses,  can  easily  be 
imagined. 

ADAPTABILITY. 

Any  form  of  reducible  hernia  is  adapted  to  this  method 
of  treatment,  providing  a  truss  can  be  obtained  that  will 
retain  the  same  under  ail  conditions  and  circumstances. 
Perfect  retention  must  absolutely  be  maintained  in  order  to 
obtain  perfect  results,  and  if  the  treatment  is  properly  applied, 
every  failure  of  cure  can  be  traced  to  negligence  in  this 
particular,  if  the  truth  is  told.  Size  of  hernia,  length  of 
time  it  has  existed,  and  age  of  patient,  while  to  a  certain 
extent  determining  the  outcome,  are  all  secondary  to  this  one 


IOO  HERNIA. 

essential ;  perfect  and  continual  retention.  Without  this  no 
cure  can  be  effected.  The  case  may  be  greatly  benefited, 
but  it  cannot  be  cured.  Impress  this  point  on  every  patient. 
Presuming  that  retention  is  perfect  the  vast  majority  of 
hernia  patients  can  be  cured.  The  time  required  will  vary 
and  will  be  determined  by  the  age  of  the  patient,  size  of 
hernia,  variety  of  hernia,  occupation  of  patient,  tension  of 
abdominal  walls,  condition  of  canal  and  obedience  of  instruc- 
tions. Recent  and  small  herniae  are  obviously  more  readily 
cured  than  those  of  long  standing  and  large  size.  If  the 
physician  employing  this  method  of  treatment  wishes  to 
guarantee  a  cure  in  every  case  accepted  for  treatment,  care- 
ful selection  of  patients  should  be  practiced,  and  no  positive 
assurance  given  until  after  the  truss  has  been  worn  for 
several  weeks  and  retention  found  perfect.  In  every  com- 
munity one  or  more  individuals  will  be  found  who  are  noted 
for  the  large  herniae  they  have,  the  size  of  which  is  often 
astonishing.  I  have  been  consulted  by  persons  with  double 
hernia  as  large  as  half  their  abdomen,  where  there  was  no 
trace  of  internal  or  external  ring,  and  all  signs  of  a  canal 
obliterated ;  the  scrotum  enlarged  to  the  size  of  a  gallon 
measure  or  more,  being  in  fact  a  part  of  the  abdomen.  To 
attempt  to  treat  cases  of  this  sort,  or  even  of  much  less 
gravity,  is  folly.  On  account  of  this  method  of  treatment 
not  being  adapted  to  all  cases  of  hernia,  physicians  opposed 
to  it  do  not  hesitate  to  condemn  it,  not  thinking  of  the  many 
instances  under  other  circumstancesi  in  which  they  make  an 
effort  to  relieve  a  patient,  knowing  that  a  cure  is  impossible 
in  the  particular  case  under  treatment. 

It  is  a  fact  worthy  of  mention,  and  I  think  of  congratu- 
lation, that  the  physicians  who  oppose  this  treatment  are 
usually  ignorant  of  its  technique,  or  being  surgeons,  recog- 
nize the  inroads  it  will  eventually  make  on  the  radical  cure 
operation. 

Barring  the  extremely  large  herniae  referred  to,  and 
those  of  moderate  to  large  size  which  cannot  be  perfectly 
retained  within  the  abdomen,  I  do  not  hesitate  to  make  the 


HERNIA.  IOI 

assertion  that  fully  90  %  of  cases  are  curable,  and  more  than 
95  %  will  be  decidedly  benefited.  I  base  my  assertions  on 
my  experience  in  a  practice  largely  devoted  to  this  specialty, 
having  treated  a  large  number  of  patients. 

TIME  REQUIRED  FOR  A  CURE. 

As  before  stated,  the  time  required  to  effect  a  cure  will 
vary  in  different  cases.  Recent  and  small  herniae  are  cured 
in  from  four  to  six  treatments,  while  the  hernia  that  has 
existed  for  a  longer  period,  and  which  is  of  larger  size,  will 
require  from  eight  to  twelve,  or  more  injections.  Patients 
are  usually  treated  once  a  week,  or  as  soon  as  the  effects  of 
the  former  injection  have  disappeared.  If  inconvenient  for 
the  patient  to  make  his  appearance  weekly,  longer  intervals 
may  be  allowed.  This  does  not  interfere  with  the  cure,  but 
necessarily  retards  it.  No  detention  from  business  or  labor 
is  necessary,  and  yet  if  the  patient  is  occupied  at  labor 
requiring  heavy  lifting,  it  is  well  to  caution  him  and  advise 
moderation,  if  possible.  Running,  jumping,  dancing  or  other 
active  exercise,  when  unnecessary,  should  be  avoided  as 
much  as  possible. 

THE  SYRINGE  AND  NEEDLE. 

As  far  as  I  have  been  able  to  ascertain,  all  individuals  or 
companies  who  are  engaged  in  the  sale  of  private  formulae 
and  fluids  for  curing  hernia,  have  special  syringes  for  sale, 
which  naturally  are  recommended  as  being  the  best  on  the 
market  and  essential  to  success.  I  have  found  these  state- 
ments contrary  to  facts,  and  my  experience  leads  me  to 
believe  that  while  the  instruments  they  offer  are  of  good 
quality  and  may  be  used  with  satisfaction,  they  are  by  no 
means  necessary  to  insure  success.  The  prices  at  which  they 
are  sold  are  usually  double  their  real  value,  and  bearing  this 
fact  in  mind,  the  object  of  their  manufacture  is  apparent. 

The  injections  may  be  given  with  an  ordinary  hypoder- 
matic syringe,  provided  with  a  set  screw  on  the  piston  by 
which  the  quantity  of  the  fluid  injected  can  be  regulated. 


102  HERNIA. 

The  needle  should  be  longer  and  heavier  than  the  ordinary, 
so  as  to  be  long  enough  to  penetrate  the  pubic  tissue,  and 
strong  enough  to  avoid  the  possibility  of  breaking  during 
the  operation.  I  find  some  additional  advantage  in  having 
a  syringe  somewhat  heavier  than  ordinary,  as  it  gives  a 
greater  firmness  in  manipulation. 

A  syringe  with  supports  at  the  piston  end,  by  which  it 
may  be  grasped  by  two  fingers  gives  a  comfortable  steadi- 
ness and  makes  slow  and  careful  injection  more  certain. 


HERNIA  SYRINGE   AND   NEEDLE. 

These  syringes,  together  with  two  suitable  needles,  can 
be  furnished  by  instrument  dealers  at  a  small  advance  over 
the  ordinary  instrument.  Three  dollars  is  amply  sufficient 
to  cover  the  cost  of  a  good,  heavy  syringe  and  a  pair  of  extra 
long  and  heavy  needles. 

There  are  several  varieties  of  hernia  needles  in  the 
market,  but  these  are  intended  especially  for  introduction 
through  the  scrotum,  and  are  made  on  the  trocar  and  canula 
order,  the  point  being  protected  by  the  sheath  after  the  skin 
of  the  scrotum  has  been  pierced,  and  then  by  gentle  manipu- 
lation is  passed  up  through  the  canal  to  the  point  at  which 
the  fluid  is  to  be  deposited.  This  method  of  introducing 
the  needle  has  never  commended  itself  to  me,  and  it  is  some- 
what gratifying  to  note  that  one  of  the  more  prominent 
physicians  interested  in  this  treatment,  and  who  devised  a 
special  needle  for  introduction  through  the  scrotum,  has 
now  also  come  to  the  conclusion  that  the  direct  introduction 


HERNIA.  103 

through  the  pubic  tissue  is  the  better  of  the  two.  In  certain 
cases,  where  there  is  either  a  difficulty  in  invaginating  the 
canal  or  in  plunging  the  needle  through  the  integument  and 
fibrous  edges  of  the  muscles,  the  needle  can  advantageously 
be  introduced  through  the  scrotal  wall.  A  sheathed  needle 
should  always  be  used  when  this  is  done,  as  it  is  practically 
impossible  to  pass  the  needle  up  to  the  point  at  which  the 
fluid  is  to  be  deposited,  with  the  point  of  the  needle  exposed. 

THE  TRUSS. 

Bearing  in  mind  the  importance  of  perfect  retention, 
the  selection  of  a  truss  deserves  special  consideration.  During 
the  several  years  in  which  I  have  paid  special  attention  to 
the  treatment  of  hernia  and  the  fitting  of  trusses,  I  have  made 
a  special  effort  to  become  familiar  with  the  different  styles 
of  trusses  on  the  market,  and  I  have  examined  and  used 
nearly  all  of  them  with  a  view  of  arriving  at  some  conclusion 
as  to  the  best  one  to  use. 

The  wire  spring  truss,  in  my  opinion,  more  fully  meets 
the  requirements  of  an  ideal  support  than  any  other,  and  it 
is  this  style  that  I  now  exclusively  employ,  except  in  very 
small  or  easily  retained  herniae,  where  I  use  the  elastic. 

There  are  a  number  of  trusses  on  the  market  which 
embody  the  wire  spring  principle,  yet  are  faulty  in  detail  and 
absolutely  worthless  for  practical  use,  especially  in  connec- 
tion with  the  treatment  of  hernia  by  injection,  where  the 
most  rigid  care  and  accuracy  is  necessary. 

Since  the  publication  of  the  second  edition  of  this  work 
I  have  devised  and  have  had  manufactured  a  truss  which  in 
my  opinion  embodies  all  that  can  be  desired  of  a  perfect  and 
practical  appliance.  It  has  been  with  some  reluctance  that 
I  have  taken  this  step,  for  fear  of  having  my  motives 
questioned  or  misconstrued,  as  according  to  the  tenets  of  the 
profession,  a  physician  cannot  embark  to  any  great  extent 
into  any  enterprise  without  having  the  cry  of  commercialism 
raised. 


104  HERNIA. 

Commercialism,  which  I  believe  is  defined  as  the  legiti- 
mate chase  after  the  elusive  dollar,  is  however  more  or  less 
interwoven  with  the  other  commendable  characteristics  of 
the  human  race,  and  without  it  the  physical  decay  and 
destruction  of  our  nation  itself  could  be  presaged. 

To  withhold  any  useful  article  or  contrivance  from 
those  for  whom  it  is  intended  and  whom  it  would  benefit,  for 
fear  of  being  accused  of  being  commercial,  is  undoubtedly 
unwise,  and  it  is  difficult  to  make  the  distinction  between 
having  an  article  marketed  by  dealers  and  receiving  a  royalty 
on  sales,  or  to  attend  to  the  filling  of  orders  personally. 
Having  therefore  considered  the  subject  in  the  various  lights, 
I  have  reached  the  conclusion  that  the  best  interests  of  those 
who  choose  to  favor  me  with  their  patronage,  and  my  own 
as  well,  will  be  best  served  by  the  course  I  have  chosen,  and 
I  therefore  recommend  the  Albright  truss  to  the  exclusion 
of  all  others  purporting  to  be  similar  in  construction  and 
involving  the  same  principle,  and  will  supply  the  profession 
according  to  demand. 

This  truss  does  not  encircle  the  body  as  do  the  hard 
rubber  spring  trusses,  but  the  rear  pad  rests  in  the  depres- 
sion behind  the  greater  trochanter,  while  the  retaining  pad 
rests  over  the  location  of  the  hernia. 

The  wire  spring  passes  from  one  to  the  other  over  the 
crest  of  the  ilium.  Two  bands  of  webbing  encircle  the 
body  and  fix  it  firmly  in  its  position. 

The  device  for  adjusting  and  holding  the  pad  in  its 
proper  position  is  an  improvement  over  the  older  patterns  and 
consists  of  a  series  of  grooves  on  the  spring  into  which 
similar  grooves  on  the  clasp  fit,  while  a  set  screw  insures 
absolute  rigidity. 

The  rear  pad  is  attached  by  means  of  a  ball  and  socket 
joint  which  is  self  adjustable  under  all  conditions  and  in 
all  positions. 

The  desirable  features  of  this  truss  are:  It  gives  that 
necessary  upward  and  inward  pressure  which  more  than  any 
other  retains  a  hernia  properly.     Mere  inward  pressure  is 


HERNIA.  I05 

not  sufficient,  while  the  downward  pressure  sometimes 
obtained  from  trusses  which  have  lost  their  shape  is  decidedly 
injurious.  With  this  truss  such  deviation  from  the  correct 
pressure  is  impossible.  The  pad  rests,  when  properly 
adjusted,  over  the  inner  ring  and  not  over  the  outer  ring 
as  is  the  case  with  many;  it  is  easily  adjusted  to  variations 
in  the  shape  of  different  persons  whose  circumferential 
measurements  are  the  same ;  it  is  comfortable  to  the  wearer 
from  the  very  moment  of  its  adjustment.  Being  so  radically 
different  from  the  usual  style  of  trusses,  patients  will 
frequently  imagine  that  it  must  of  necessity  be  uncomfort- 
able, yet  they  can  be  assured  that  such  is  not  the  case.  Apart 
from  an  occasional  chafing  due  to  a  slight  curve  of  the  body 
which  may  have  been  overlooked  in  fitting,  but  which  can 
be  readily  overcome,  no  difficulty  exists  from  this  cause. 

Last  but  not  least,  is  the  assurance  that  when  once 
properly  adjusted  it  cannot  possibly  move  from  the  seat  of 
the  hernia,  regardless  of  the  position  of  the  wearer.  So 
firmly  indeed  is  it  held  in  position  that  it  is  with  difficulty 
that  the  proper  adjustment  is  disturbed  without  loosening 
the  bands,  even  when  attempting  to  do  so. 

VARIETIES  OF  PADS. 

The  pads  with  which  my  truss  may  be  equipped  com- 
prise all  the  usual  styles  and  in  addition  a  new  style  of  spring 
pad.  This  consists  of  an  oblong  border  of  leather  covered 
rubber  and  a  distinctly  separate  oblong  central  hard  rubber 
pad  which  adjusts  itself  to  the  various  degrees  of  pressure 
by  means  of  an  enclosed  spring.  Being  automatic  in  its 
action  it  is  especially  valuable  in  cases  where  undue  strain- 
ing is  liable  to  occur,  as  in  lifting,  coughing,  etc.  As  a  pad 
suitable  to  all  cases  it  is  perhaps  the  most  desirable.  In 
addition,  the  hard  rubber,  cedar,  water  and  coil  spring  can 
be  furnished.  Elastic  trusses  fitted  with  either  of  these  pads 
can  also  be  furnished. 

One  occasionally  meets  with  a  hernia  of  such  magnitude 
or  irregularity  that  no  ready-made  contrivance  will  retain  it, 


io6 


HERNIA. 


nor  can  one  be  devised  in  all  cases,  yet  as  this  subject  is 
here  viewed  only  in  the  light  of  rendering  a  hernia  amenable 
to  treatment  by  the  injection  method,  the  subject  of  special 
appliances  need  not  be  discussed,  as  it  is  safe  to  assume  that 
as  a  rule,  any  hernia  that  cannot  be  retained  by  my  truss  and 
the  pads  with  which  it  is  regularly  fitted,  is  not  a  suitable 
case  for  treatment.  In  a  somewhat  extensive  practice  of  this 
specialty  I  have  treated  but  few  cases  in  which  other  than 
the  regular  equipment  was  required. 


THE   ALBRIGHT  TRUSS,    SHOWING  NEW   AUTOMATIC   SPRING   PAD. 


HERNIA. 


IO; 


When  a  suitable  truss  is  worn  by  the  patient  when  he 
applies  for  treatment,  no  matter  what  its  style,  if  it  fulfills 
the  requirements  and  retains  the  hernia  perfectly,  no  change 
is  advised. 

See  illustrations  of  truss  and  note  particularly  the  posi- 
tion of  the  truss  on  the  body.  Proper  and  exact  fitting  is 
essential  to  success.  The  size  of  the  truss  required  will  be 
found  by  measuring  the  circumference  of  the  body  on  a  line 
with  the  point  at  which  the  hernia  first  appears. 


THIS   ILLUSTRATES   THE   POSITION   THE   TRUSS  SHOULD  OCCUPY 

WHEN  PROPERLY   ADJUSTED. 

FRONT  VIEW. 


io8 


HERNIA. 


THIS    ILLUSTRATES   THE   POSITION   THE   TRUSS   SHOULD   OCCUPY 

WHEN   PROPERLY   ADJUSTED. 

REAR  VIEW. 


THIS   ILLUSTRATFS   THE   MECHANISM   OF   THE   NEW 
AUTOMATIC   SPRING   PAD. 

Explanation  of  Cut. — The  central  hard  rubber  oral  pad 
G,  is  suspended  on  the  coil  spring  E,  which  is  attached  to  the 
button  shank  B,  and  all  attached  t'<  the  fixed  plate  C.  This 
Suspension  of  the  pad  in  the  center  of  a  fixed ,  soft  rubber  ring 
cushion  F,  permits  a  gentle  and  beneficial  extra  pressure  on 
the  internal  ring  without  the  risk  of  the  pad  sinking  in  too 
far.     Its  action  is  entirely  automatic. 


HERNIA.  IO9 


FLUIDS  FOR  INJECTION. 

When  one  considers  the  numerous  compounds  used,  all 
of  different  composition,  by  the  many  successful  hernia 
specialists,  but  one  impression  is  made  and  but  one  conclusion 
can  be  reached;  that  the  application  of  the  treatment;  the 
method  of  injecting;  the  technique  of  the  operation;  are 
undoubtedly  of  more  importance  than  the  fluid  used.  In 
other  words,  no  matter  what  the  composition  of  the  fluid,  if 
the  injections  are  not  properly  made  the  result  will  be 
unsatisfactory;  yet  on  the  other  hand  it  is  also  true  that  no 
matter  how  skillfully  the  treatment  is  applied,  unless  the 
fluid  used  be  a  proper  one,  the  result  will  also  be  disappoint- 
ing-. It  is  probably  true  that  one  could  name  a  hundred 
drugs  which  could  rationally  be  incorporated  into  a  fluid  for 
the  injection  treatment  of  hernia,  and  it  is  only  by  experi- 
ment and  observation  that  the  compounds  most  successfully 
employed  are  suggested  and  perfected.  While  injections  of 
alcohol,  iodine,  creasote,  sulphate  of  zinc  and  other  single 
remedies  may  cure  a  case  now  and  then,  it  must  not  be 
inferred  that  uniform  success  will  follow  their  use  in  a  num- 
ber of  cases,  as  repeated  trials  will  prove  to  the  satisfaction 
of  any  one  who  is  of  the  opinion  that  any  irritant  will  suf- 
fice. In  selecting  ingredients  with  which  to  compound  a 
fluid  that  will  yield  satisfactory  results  in  a  large  percentage 
of  cases,  certain  essential  indications  must  be  met,  namely : 
a  proper  degree  of  irritation  must  be  produced  to  cause  a 
sufficient  quantity  of  plastic  exudation ;  hardening  of  the  tis- 
sues after  the  exudation  so  as  to  render  re-absorption  impos- 
sible ;  solidification  of  the  exudate  and  its  stimulation  to  tissue 
formation ;  a  certain  degree  of  anesthesia ;  and  always, 
asepsis. 

The  fluids  used  by  the  early  operators  who  employed 
this  method  of  curing  hernia,  were,  as  before  stated,  more 
or  less  crude  and  unsatisfactory.  The  results  were  not  only 
unsatisfactory  in  many  cases,  but  frequently  the  reaction  was 


110  HERNIA. 

such  that  its  general  use  was  abandoned  on  account  of  the 
dangers  attending  it. 

In  the  light  of  more  recent  investigation  and  experiment, 
our  knowledge  of  chemistry  has  been  called  to  our  aid,  and 
substances  which  by  themselves  would  be  worthless  or  harm- 
ful, may  by  skillful  combination  be  rendered  safe  and  useful 
agents. 

The  following  formulae  for  hernial  fluids  are  those 
upon  which  I  now  most  rely  and  employ  to  the  practical 
exclusion  of  all  others,  except  for  the  purpose  of  experi- 
ment. Neither  of  them  was  perfected  in  a  day,  but  by  many 
trials  and  experiments,  both  clinically  and  chemically,  during 
a  period  of  seven  years  or  more,  their  present  state  of  perfec- 
tion was  attained.  These  fluids  have  been  used  by  several 
hundred  physicians  whom  I  have  supplied,  and  every  claim 
I  have  ever  made  has  been  substantiated  and  endorsed  by 
many  of  them.  I  therefore  do  not  hesitate  to  commend  them 
to  the  profession  as  worthy  of  their  confidence. 

The  following  is  the  formula  of 

Universal  Hernial  Fluid  No.  i. 

1^      Sulphate  of  Zinc 3  j. 

Carbolic  Acid,  cryst gr.  xl. 

Guaiacol    n\    lx. 

Powd.   Cantharides gr.  xxv. 

Fl.  Ext.  Quercus  Alba fl.  %  j. 

Fl.  Ext.  Hamamelis  Virg fl.  %  j. 

Glycerite  of  Tannic  Acid fl.  5  j. 

Glycerine,  C.  P q.  s.  ad.  fl.  %  v. 

Mix  as   directed. 

Mix  the  carbolic  acid  and  guaiacol  with  the  glycerine 
and  transfer  into  an  eight  ounce  bottle.  Triturate  the  sul- 
phate of  zinc  and  cantharides  separately  until  reduced  to  a 
fine  powder  and  add  these,  with  the  other  ingredients,  to  the 
contents  of  the  bottle.     Mix  thoroughly  and  place  the  bottle 


HERNIA.  1 1  I 

at  some  convenient  point  and  shake  the  mixture  three  or 
four  times  a  day  for  at  least  thirty  days,  when  it  may  be 
filtered  and  is  ready  for  use. 

All  utensils  used  in  its  manufacture  should  be 
thoroughly  sterilized,  as  the  introduction  of  germs  into  the 
inguinal  canal  is  no  doubt  a  frequent  cause  of  the  serious 
inflammation  sometimes  reported  by  physicians  using  fluids 
which  have  been  extemporaneously  or  carelessly  prepared. 
The  presence  of  carbolic  acid  or  guaiacol  in  a  fluid  is  not 
sufficient  to  render  it  sterile,  as  certain  bacteria  flourish  in 
the  presence  of  carbolic  acid,  and  the  necessary  precautions 
must  be  taken  in  its  manufacture  if  all  possibility  of  infection 
would  be  avoided. 

The  entire  absence  of  the  slightest  unpleasant  effect  from 
the  use  of  fluids  prepared  by  myself  is  perhaps  largely  due 
to  the  care  exercised  in  their  manufacture. 

The  following  is  the  formula  of 

Universal  Hernial  Fluid  No.  2. 

J£      Sulphate  of  Zinc 5  j. 

Carbolic  Acid,  cryst n\    xl. 

Creasote    -^    iXXx. 

Fl.  Ext.  Thuja  Occ fl.  5  ss. 

Fl.  Ext.  Ouercus  Alba fl.  %  j. 

Fl.  Ext.  Hamamelis  Virg fl.  5  ij. 

Glycerine,  C.  P q.  s.  ad.  fl.  5  v. 

Mix  as  directed. 

Mix  the  carbolic  acid  and  creasote  with  the  glycerine 
and  transfer  into  an  eight  ounce  bottle.  Triturate  the  sul- 
phate of  zinc  until  reduced  to  a  fine  powder  and  with  the 
fluid  extract  of  white  oak  and  other  ingredients,  add  to  the 
contents  of  the  bottle.  Mix  thoroughly  and  place  the  bottle  at 
some  convenient  point  and  shake  the  mixture  three  or  four 
times  a  day  for  at  least  thirty  days,  when  it  may  be  filtered 
and  is  ready  for  use. 

Note. — The  creasote  used   is   not  beechwood  creasote, 


112  HERNIA. 

but  that  obtained  from  the  destructive  distillation  of  coal  tar. 
Some  physicians  located  in  the  West  have  written  me  stating 
that  the  article  could  not  be  obtained,  yet  as  it  is  so  common 
in  the  East  it  seems  hardly  possible.  In  this  section  all  drug- 
stores sell  it  as  a  remedy  for  toothache. 

The  same  precautions  should  be  taken  in  the  manufac- 
ture of  this  fluid  as  in  the  preceding  one. 

The  purpose  of  allowing  the  mixture  to  stand  for  thirty 
days  before  filtering  is  to  allow  the  chemical  changes  to  take 
place,  as  for  example  between  the  zinc  sulphate,  carbolic 
acid  and  the  tannin  in  the  white  oak  and  witch-hazel,  and  in 
the  glycerite  of  tannin  in  fluid  No.  I ;  and  to  prevent  pre- 
cipitation after  filtration.  If  filtered  shortly  after  the  mixture 
is  made  there  will  be  considerable  precipitation  within  a  few 
days  thereafter. 

In  as  much  as  I  here  mention  two  fluids  for  injection, 
the  question  will  naturally  arise,  when  shall  No.  I  be  used ; 
when  shall  Xo.  2  be  used;  which  is  the  better  of  the  two; 
why  not  use  only  one  fluid?  etc. 

Answering  these  questions  is  a  task  in  which  one  may 
find  difficulty  in  expressing  himself  clearly,  as  practical 
experience  is  the  only  real  and  true  guide. 

My  experience  with  both  fluids  has  been  quite  extended 
and  results  so  eminently  gratifying,  that  were  I  asked  to 
select  one  and  use  it  exclusively,  the  choice  would  cause  me 
considerable  concern. 

Either  fluid  is  adapted  to  all  cases,  and  all  curable  cases 
will  be  cured  by  the  use  of  either  fluid.  The  difference  how- 
ever is  this ;  Fluid  No.  1  is  more  irritating  and  causes  rather 
more  exudation  than  No.  2.  This  is  chiefly  due  to  the  Can- 
tharides  which  it  contains ;  also  more  astringent  on  account  of 
the  larger  quantity  of  Tannic  acid,  as  the  No.  2  fluid  con- 
tains no  tannic  acid  other  than  that  furnished  by  the  fluid 
extracts  of  white  oak  and  witch-hazel.  For  these  reasons 
No.  1  is  more  especially  indicated  in  the  treatment  of  older 
persons,  or  in  cases  where  the  hernia  has  existed  for  many 


HERNIA.  II3 

years  and  caused  the  surrounding  tissues  to  become  more 
hardened  and  fibrous. 

In  these  cases  the  irritation  necessary  to  produce  the 
required  exudation  must  be  stronger  than  in  young  and 
recent  cases,  where  these  changes  have  not  yet  occurred. 
One  may  however  also  occasionally  find  one  of  the  latter 
cases  in  which  the  exudation,  inflammation  and  usual  tender- 
ness is  not  developed  by  the  quantity  of  No.  2  usuallv 
injected,  and  in  these  cases  it  is  also  recommended  that  the 
No.  1  fluid  be  substituted.  While  larger  injections  of  No.  2 
would  have  practically  the  same  effect,  causing  a  relatively 
greater  amount  of  irritation,  there  is  this  objection;  when 
the  quantity  injected  is  too  large,  the  law  of  gravitation 
asserts  itself,  and  the  fluid,  instead  of  remaining  permanently 
at  the  desired  point,  gravitates  either  downward  into  the 
scrotum,  or  if  the  patient  is  lying  on  an  operating  chair 
with  the  head  lower  than  the  feet  (as  described  later  on),  it 
may  flow  into  the  abdominal  cavity.  Neither  of  these  cir- 
cumstances would  give  rise  to  any  reasons  for  alarm,  as  the 
fluid  being  aseptic,  would  do  no  harm,  merely  exciting 
an  innocent  inflammation,  but  not  being  part  of  the  treat- 
ment, such  irregularities  are  to  be  avoided. 

Summarizing  then,  the  difference  between  the  fluids  is 
practically  a  matter  of  strength.  The  same  results  will  be 
attained  by  the  use  of  either  fluid  if  the  dosage  is  regulated. 
No  fixed  rule  for  dosage  can  be  given.  Certain  cases  will 
be  cured  by  the  average  injection  of  three  minims,  while 
others  will  require  an  average  of  ten.  When  an  injection 
of  ten  to  fifteen  minims  of  Fluid  No.  2  is  not  followed  by  the 
proper  degree  of  reaction,  it  may  be  still  further  increased,. 
or  Fluid  No.  1  resorted  to  and  given  in  five  to  ten  minim 
doses.  If  Fluid  No.  1  be  used  in  the  beginning  of  a  case,, 
and  the  quantities  injected  do  not  produce  too  much  inflam- 
mation, no  change  will  be  necessary.  Fluid  No.  1  can  be- 
adapted  to  the  use  of  all  cases,  attention  being  given  to- 
dosage.  No.  2  is  recommended  in  children  or  in  cases  where 
small  doses  of  the  other  irritate  too  much.    As  the  physician 


114  HERNIA. 

becomes  familiar  with  the  treatment,  and  bears  in  mind 
that  the  dose  of  any  fluid,  no  matter  what  its  composition, 
is  to  be  regulated  by  the  effect  produced  by  former  injec- 
tions, he  will  have  no  trouble  whatever,  but  he  will  be 
entirely  guided  by  his  good  judgment. 

Physicians  who  do  not  have  the  facilities  or  inclination 
to  prepare  fluids  according  to  my  formulae,  can  obtain  either 
fluid,  prepared  according  to  the  methods  described,  at  the 
rate  of  One  Dollar  per  bottle,  containing  one  ounce  of  fluid. 
Sent  prepaid  by  mail.  .  This  quantity  will  be  sufficient  to 
treat  six  or  more  patients. 

I  claim  no  proprietary  interest  in  either  of  my  fluids, 
and  any  one  possessing  ordinary  skill  in  compounding  medi- 
cines can  prepare  them  properly,  due  caution  being  observed 
in  the  purchase  of  the  ingredients.  My  only  claim  is  that 
when  prepared  by  myself  they  are  guaranteed  to  be  accurate, 
clean,  effective,  and  as  reliable  as  pure  drugs  and  careful 
attention  to  detail  can  make  them.  Less  quantities  than  the 
above  will  not  be  sold,  as  the  fluids  are  prepared  in  large 
quantities  and  immediately  bottled  and  sealed. 


HERXIA.  115 

DIRECTIONS  FOR  TREATMENT. 


Technique  of  the  Operation. 


GENERAL  DIRECTIONS. 


First,  if  the  patient  is  not  already  supplied  with  a  well 
fitting  truss,  one  that  perfectly  retains  the  hernia  under  all 
conditions  and  circumstances,  procure  one  that  will  do  so. 
If  the  patient  does  not  already  wear  a  truss,  have  him  do  so 
for  a  few  weeks  before  beginning  the  treatment.  If  the  her- 
nia exhibits  a  tendency  to  protrude  during  the  night  while 
the  patient  is  in  bed,  the  truss  must  be  worn  constantly.  If 
the  day  truss  should  prove  uncomfortable  at  night,  an  elastic 
support  may  be  substituted.  If  there  is  no  such  tendency, 
the  truss  may  be  removed  after  lying  down,  but  it  must  be 
replaced  before  rising.  Do  not  begin  the  treatment  until  the 
patient  tells  you  that  the  hernia  never  comes  down,  as  it 
will  be  useless  to  try  to  close  the  canal  as  long  as  the  hernia 
occasionally  descends  and  again  opens  and  distends  it.  After 
the  treatment  is  begun  it  is  a  good  plan  to  have  the  patient 
wear  a  light  support  while  in  bed.  This  support  may  be 
either  an  ordinary  elastic  truss  or  a  homemade  appliance. 
A  simple  device  of  this  kind  can  be  made  by  sewing  a  lump 
of  lead,  half  spherical  in  size,  between  two  pieces  of  cloth, 
made  to  encircle  the  body,  with  an  under  strap  to  keep  it  in 
place.  The  lead  can  be  molded  in  this  fashion  by  pouring 
the  molten  metal  into  a  dry  cup  and  allowing  it  to  cool. 
Place  the  round  side  inwards.  I  formerly  did  not  insist  on 
this  detail,  but  experience  has  taught  me  that  the  procedure 
is  a  wise  one.  Patients,  when  informed  that  a  truss  need 
not  be  worn  when  in  bed,  are  liable  to  form  the  opinion  that 
as  long  as  they  remain  in  bed,  whether  in  the  upright  or 
horizontal  position,  the  truss  can  be  laid  aside.  Of  course 
the  more  intelligent  patients  will  understand  what  is  meant, 


Il6  HERNIA. 

but  many  will  interpret  your  directions  literally.  As  an 
illustration,  I  will  mention  a  case  that  gave  me  considerable 
trouble.  I  could  get  no  clue  to  the  secret  until  inadvertently 
the  patient  informed  me  that  the  hernia  gave  him  "some 
trouble"  while  cohabiting.  In  this  case,  because  he  was  in 
bed  at  the  time,  he  followed  my  instructions  and  did  not 
wear  the  truss.  I  now  instruct  all  male  patients  to  wear  the 
truss  when  this  act  is  performed. 

TREATMENT.  Place  the  patient  in  a  reclining  posi- 
tion, remove  the  truss  and  clean  the  pubes  with  some  anti- 
septic solution.  If  the  hernia  shows  a  tendency  to  descend 
during  this  manipulation,  tilt  the  chair  or  table  backward 
sufficiently,  raising  the  feet  higher  than  the  head,  until 
the  hernia  slips  into  the  abdomen.  Now  draw  fluid  into 
your  syringe,  exclude  the  air  by  elevating  the  needle  and 
pressing  the  piston  until  a  drop  of  fluid  escapes  without  bub- 
bling, wipe  the  needle  clean  of  fluid,  set  the  set  screw  on  the 
piston  to  the  amount  you  wish  to  inject,  invaginate  the  canal 
with  the  forefinger  of  the  left  hand,  introduce  the  needle 
through  the  pubic  tissue  into  the  canal  with  the  right  hand, 
and  make  the  injection  at  the  point  indicated  in  the  special 
directions.  Remove  the  needle,  massage  the  parts  for  a 
minute,  replace  the  truss  and  let  the  patient  go  about  his 
business.  The  operator,  if  right  handed,  should  stand  on 
the  left  side  of  the  patient,  whether  operating  on  either  a 
right  or  a  left  hernia.  If  left  handed,  the  opposite  applies. 
Before  inserting  the  needle,  grasp  the  integument  with  the 
forefinger  in  the  canal  and  the  thumb  of  the  same  hand  and 
elevate  them  slightly.  This  allows  a  space  between  the 
finger  and  the  floor  of  the  canal,  on  which  the  cord  and 
vessels  lie,  and  prevents  all  danger  of  injuring  them.  Pass 
the  needle  in  a  lateral  direction  through  the  pubic  tissues, 
directly  beyond  the  end  of  the  inside  finger,  until  the  needle 
has  entered  the  canal.  This  can  be  determined  by  directing 
the  point,  now  inside,  toward  the  end  of  the  finger.  If  cor- 
rectly located,  there  will  be  nothing  between  the  finger  in  the 


HERNIA. 


117 


THIS   ILLUSTRATES  THE   METHOD   OF   GIVING   THE   INJECTIONS 
IN   THE  TREATMENT  OF   HERNIA. 


canal  and  the  needle  point,  but  the  scrotum  which  was 
brought  up  with  it.  The  prick  of  the  needle  can  easily  be 
felt  on  the  finger  of  the  operator. 

After  the  injection  has  been  made,  withdraw  needle, 
return  the  fluid  remaining  in  the  syringe  into  the  vial,  cleanse 
the  needle  by  drawing  a  little  alcohol  through  it  and  place  it 
in  either  a  solution  of  carbolic  acid  or  a  fresh  and  clean  piece 


Il8  HERNIA. 

of  absorbent  cotton.     Before  using  the  needle  and  syringe 
again,  cleanse  with  alcohol  in  the  manner  just  mentioned. 

A  short  time  after  the  injection  has  been  made,  the 
patient  will  experience  a  feeling  similar  to  a  bruise  at  the 
point  at  which  the  injection  has  been  made,  which  will  con- 
tinue for  several  days.  This  is  due  to  the  irritation  caused 
by  the  fluid  and  the  resulting  inflammatory  action.  This 
inflammation  causes  the  exudation  necessary  for  the  healing 
process.  The  amount  of  inflammatory  action  differs  in  differ- 
ent persons,  and  it  should  be  merely  sufficient  to  cause  a 
moderate  amount  of  uneasiness,  and  not  sufficient  to  inca- 
pacitate the  patient.  In  giving  the  dosage  of  the  fluid  I 
shall  specify  minims,  not  drops.  One  minim  of  an  alcoholic 
fluid  is  not  the  same  as  one  drop,  and  it  varies  also  accord- 
ing as  to  whether  the  fluid  is  dropped  from  a  graduate  or 
through  needles  of  different  caliber.  According  to  the  needle 
I  use,  one  minim  is  equal  to  five  drops  as  they  fall  from  the 
needle.  This  is,  however,  unimportant.  The  piston  of  the 
syringe  being  graduated  and  being  supplied  with  a  set  screw, 
the  number  of  minims  can  be  accurately  ascertained.  No 
matter  which  fluid  is  used,  always  begin  with  one  minim,  or 
even  less,  and  note  the  result.  Ask  the  patient  to  return  in 
a  day  or  two,  and  if  there  is  no  inflammatory  action  worth 
noting,  repeat  the  injection,  giving  two  minims,  and  again 
ask  him  to  report  in  a  few  days.  Be  guided  by  the  effect 
produced  and  repeat  or  not  according  to  the  condition  of  the 
patient.  Never  inject  when  there  is  inflammatory  action 
present.  In  this  manner  the  dose  can  be  regulated,  and 
when  the  quantity  that  causes  the  proper  amount  of  soreness 
is  ascertained,  continue  that  dose  until  its  effects  are  less 
marked,  when  another  increase  can  be  made.  In  the 
majority  of  cases,  four  to  five  minims  will  be  sufficient  to 
produce  the  desired  action,  and  yet  occasionally  a  person  will 
be  found  in  whom  ten  to  fifteen  minims  have  to  be  used  in 
order  to  do  this.  If  the  inflammatory  action  is  such  that  the 
patient  cannot  exercise  freely  and  follow  his  usual  occupa- 
tion, the  dose  given  was  too  large,  and  less  must  be  given  in 


HERNIA.  119 

the  future.  Cases  in  which  the  inflammation  has  been 
unusually  strong  will  be  found  well  advanced  toward  the 
cure,  after  it  subsides,  which  it  will  do  after  twenty-four  to 
forty-eight  hours.  This  is  the  compensation  for  the  incon- 
venience experienced.  Beyond  the  discomfort  of  the  patient, 
there  is  no  undesired  effect.  After  the  effects  of  one  injec- 
tion have  worn  off,  another  may  be  given,  no  matter  whether 
it  is  in  three  days  or  two  weeks.  Instruct  the  patient  to 
report  as  soon  as  the  soreness  has  disappeared,  when  you  will 
again  treat  him.  No  interference  with  the  ultimate  cure 
will  be  experienced  if  the  injections  are  given  at  longer  inter- 
vals than  as  indicated  by  the  disappearance  of  the  soreness, 
but  the  period  in  which  the  cure  will  be  effected  will  neces- 
sarily be  lengthened.  Should  sympathetic  swelling  occur  in 
either  the  cord  or  adjacent  structures,  no  alarm  need  be  felt. 
Injury  to  the  cord  or  vessels  is  impossible  if  directions  for 
introducing  the  needle  are  followed.  If  it  should  occur 
through  clumsy  work  at  this  point,  and  much  swelling 
occur,  treat  as  you  would  inflammation  anywhere.  I  have 
never  seen  a  case  of  this  sort,  but  have  heard  of  it  through 
other  writers. 

In  the  Female  the  same  general  rules  apply,  but  invagi- 
nation can  scarcely  be  accomplished.  In  large  herniae  a 
manipulation  that  approaches  invagination  can  be  prac- 
ticed, but  in  the  smaller  cases  this  is  impossible.  Here  the 
round  ligament  is  used  as  a  guide  for  depth,  and  after  grasp- 
ing the  integument  with  the  forefinger  and  thumb  of  the 
left  hand,  pass  the  needle  through  it  from  above  downward 
on  a  line  with  the  body,  so  that  after  the  needle  has  pierced 
the  tissues  and  passed  through  them,  the  point  will  be  located 
under  the  finger  and  thumb. 

After  the  needle  has  been  introduced,  still  elevating  the 
tissues,  raise  the  syringe  so  that  it  will  be  at  right  angles  to 
the  body,  pointing  directly  downward.  The  injection  should 
always  be  made  where  the  protrusion  first  appears,  and  the 
needle  should  be  introduced  directly  over  this  spot.  This 
point  should  be  marked  with  a  blue  pencil  while  the  patiert 


120  HERNIA. 

is  standing,  so  as  to  easily  locate  it  while  lying  down.  The 
round  ligament  can  easily  be  located  by  its  tough,  cord-like 
touch. 

The  injection  should  be  made  at  about  the  same  depth 
as  this  ligament  is  felt.  While  women  are  not  as  easily 
treated  as  men,  the  operation  is  not  at  all  difficult,  and  if 
properly  injected,  they  will  be  cured  in  less  time  than  a  simi- 
lar hernia  in  a  man,  as  the  hernial  canal  is  usually  smaller. 
Flabby  abdominal  walls  render  a  cure  more  difficult  and 
tedious. 

After  four  to  six  injections  have  been  made,  or  more 
in  large  and  long  standing  cases,  and  the  hernia  has  not  been 
down  during  that  time,  and  there  is  reason  to  suppose  that 
the  treatment  has  progressed  favorably,  a  test  may  be  made. 
Be  sure  to  instruct  the  patient  not  to  dare  to  make  an  effort 
to  test  himself  during  the  treatment,  but  insist  that  he  fol- 
low instructions  in  this  particular  explicitly.  The  manner 
of  making  a  test  is  similar  to  the  diagnosis  of  hernia.  The 
first  test  should  be  made  while  the  patient  is  lying  down. 
Remove  the  truss  and  instruct  the  patient  to  cough.  If  no 
impulse  is  noted  while  in  this  position,  the  patient  may  rise 
and  the  experiment  be  repeated.  Always  press  your  hand 
firmly  against  the  parts  while  the  patient  coughs  for  a  test, 
so  that  in  case  there  should  be  a  weakness  present,  the  her- 
nia would  not  descend  and  thus  do  considerable  damage  to 
the  adhesions  which  had  formed.  If  no  impulse  is  noticed 
while  patient  coughs  while  standing,  the  treatment  may  be 
discontinued  temporarily,  but  the  patient  instructed  to  con- 
tinue wearing  his  truss  for  a  month  or  more,  and  report  at 
the  end  of  that  time.  The  night  support  may  now  be  dis- 
continued. After  a  month  the  patient  is  again  tested,  and  if 
no  impulse  is  felt,  the  case  may  be  discharged  with  direc- 
tions to  wear  the  truss  for  another  month  while  at  work,  if 
a  laboring  man,  but  to  remove  it  while  about  the  house  or 
when  not  at  work.  After  that  time  it  may  be  discarded 
altogether.     If  the  patient's  occupation  is  of  a  light  nature, 


HERNIA.  121 

the  truss  may  be  discarded  entirely  after  wearing  it  a  month 
after  the  test. 

In  case  an  impulse  is  noticed  when  the  test  is  made,  the 
treatment  must  be  continued  as  before,  and  occasionally 
tested  until  the  desired  results  are  obtained. 

After  a  few  injections  are  made,  small  nodules  will  be 
noticed  to  be  forming  in  the  canal.  This  is  as  it  should  be, 
and  represents  the  new  tissue  formation  which  is  taking 
place  and  which  is  necessary  to  the  closure  of  the  canal.  In 
large  herniae,  where  the  canal  is  more  distended  and  the 
surface  much  larger,  two  injections  may  be  given  at  one 
visit,  one  nearer  the  outer  margin  of  the  ring,  and  the  other 
more  toward  the  inside.  Young  and  middle  aged  persons 
make  the  best  subjects,  although  persons  well  advanced  in 
years  can  be  cured  if  sufficient  time  is  allowed.  Old  per- 
sons usually  require  larger  doses  than  others  on  account  of 
their  tissues  not  being  as  highly  vascular  and  active  in  pro- 
ducing the  exudate  as  in  younger  persons.  Infants  and 
children  under  five  or  six  years  of  age  are  usually  unsatis- 
factory patients,  as  they  cannot  describe  the  degree  of  inflam- 
mation present,  they  usually  cry  and  struggle  during  the 
treatment,  which  causes  the  hernia  to  descend,  remove  or 
disturb  the  truss  if  not  continually  watched,  and  as  a  rule 
cause  more  vexation  than  their  parents  are  willing  to  pay 
for.  If  you  should  accept  children  for  treatment,  do  not  fall 
into  a  common  error  and  treat  them  for  half  the  usual  fee,  as 
after  a  short  experience  you  will  regret  it.  If  I  should  ever 
undertake  to  cure  a  child  of  the  age  given,  my  charges  would 
be  a  certain  fee  per  treatment  and  no  promises  made.  Chil- 
dren of  the  ages  of  eight  to  ten  years  are  excellent  subjects, 
and  are  usually  rapidly  and  perfectly  cured. 

In  Double  Hernia,  each  side  may  safely  be  treated  at 
each  visit,  the  soreness  resulting  being  no  more  than  if  only 
one  side  is  injected. 

Some  physicians  advise  the  use  of  an  anesthetic  before 
introducing  the  needle,  usually  cocaine,  but  this  is  entirely 
unnecessary.     The  pubic  tissues   are  not  sensitive,   and  in 


122  HERNIA. 

persons  with  hernia  are  usually  thinner  than  in  sound  per- 
sons. Use  a  sharp  needle  and  introduce  quickly  and  none 
will  complain  of  the  very  slight  pain  caused  by  the  prick  of 
the  needle.  Others  recommend  the  addition  of  cocaine  to 
the  fluid.  This  may  be  necessary  with  some  fluids,  but  I 
have  never  heard  any  one  complain  of  more  than  a  slight 
burning,  and  not  more  than  can  easily  be  borne  for  a  few 
minutes.  Again,  the  use  of  cocaine  combined  with  the 
fluid  is  not  theoretically  nor  practically  of  value.  Before  the 
cocaine  could  anesthetize  the  membrane,  the  irritants  would 
make  their  presence  felt,  as  cocaine  requires  a  short  time 
in  which  to  act.  If  cocaine  is  ever  used  inside,  it  should  be 
injected  a  minute  or  two  before  the  fluid.  I  have  no  use  for 
it  and  do  not  advise  it.  With  either  of  the  fluids  given  here 
it  is  unnecessary.  A  hot  water  bag  before  and  after  injec- 
tion, is  also  sometimes  recommended.  It  is  applied  directly 
over  the  seat  of  the  hernia  after  the  injection  has  been  made, 
and  allowed  to  remain  five  or  ten  minutes. 

SPECIAL  DIRECTIONS. 

Read  Carefully. 

In  order  that  these  directions  may  be  fully  and  clearly 
understood,  a  brief  outline  of  the  anatomy  of  hernia  will  be 
given.  A  thorough  familiarity  with  this  subject  is  essential 
for  the  correct  diagnosis  and  proper  treatment  of  hernia. 

OBLIQUE  INGUINAL  HERNIA. 

This  variety  of  hernia  is  sometimes  called  Indirect  or 
External  Oblique.  In  this  variety  the  intestines  escape  from 
the  abdominal  cavity  at  the  internal  ring,  where  the  sper- 
matic cord  passes  out  of  the  abdomen,  taking  the  same 
course  as  the  cord  along  the  inguinal  canal,  through  the  ex- 
ternal ring  and  into  the  scrotum.  When  a  hernia  passes 
through  the  external  ring  it  is  termed  a  complete  hernia,  if 
not,  an  incomplete.  The  external  form  of  hernia  is  so  called 
because  it  passes,   in   its  descent,  to  the  outer  side  of,  or 


HERNIA. 


123 


external  to  the  epigastric  artery.    The  cord  is  always  behind 
the  hernia. 

DIRECT  OR  INTERNAL  INGUINAL  HERNIA. 

In  this  variety  the  protrusion  passes  directly  through 
the  abdominal  walls  and  descends  through  the  external  ring 
into  the  scrotum.  It  is  called  internal,  because  it  passes,  in 
its  descent,  to  the  inner  side  of  the  epigastric  artery. 

In  some  cases  this  form  of  hernia  breaks  into  the. ingui- 
nal canal  and  passes  down  through  it.  In  the  majority  of 
cases,  however,  it  passes  directly  through  the  tissues  and 
into  the  external  ring.  If  a  direct  hernia  passes  into  the 
inguinal  canal  but  does  not  pass  through  the  external  ring, 
it  is  called  an  incomplete  direct  hernia.  Direct  hernia  is  not 
near  as  frequently  met  with  as  the  oblique  form,  the  per- 
centage being  probably  one  in  five  or  eight.  The  differen- 
tial diagnosis  between  the  two  varieties  can  be  made  by  the 
location  of  the  point  at  which  protrusion  is  first  noticed, 
being  more  external  in  the  oblique  form. 

The  direction  in  which  a  direct  hernia  descends  is 
always  more  directly  downward,  or  may  even  be  slightly  out- 
ward from  the  point  at  which  the  protrusion  is  first  noticed, 
while  in  the  oblique,  it  is  always  downward  and  inward 
pointing  toward  the  pubic  bone.  Bearing  in  mind  the  direc- 
tion of  the  inguinal  canal,  the  diagnosis  can  easily  be  made. 
When  the  two  forms  exist  in  the  same  person,  as  I  have 
seen  several  times,  the  diagnosis  is  likely  to  be  difficult, 
unless  this  possibility  is  borne  in  mind. 

Either  of  the  other  varieties  of  hernia  are  readily 
recognized  and  no  special  reference  need  be  made  to  them 
here.  A  careful  detailed  study  of  hernia  will  materially 
benefit  any  practitioner  who  wishes  to  make  a  success  of  the 
injection  method  of  treatment. 


124  HERNIA. 


Where  to  Deposit  the  Fluid. 

In  Oblique  Hernia,  invaginate  the  canal  with  the  left 
forefinger,  as  directed  in  the  general  directions,  carrying  the 
end  of  the  finger  well  up  to  the  internal  ring,  where  the 
hernia  escapes  from  the  abdomen.  Introduce  the  needle  as 
directed  before,  about  half  an  inch  below  this  point,  and  after 
the  needle  has  been  passed  through  the  tissues,  direct  its 
point  upward  toward  the  internal  ring.  As  the  finger  in  the 
canal  is  elevating  the  tissues,  the  needle  can  be  turned  in  this 
manner  without  touching  any  of  the  contents  of  the  canal. 
Deposit  the  fluid  as  close  to  the  internal  ring  as  possible, 
rotating  the  needle  somewhat  during  the  expulsion  of  the 
fluid,  so  as  to  distribute  it  well.  When  the  internal  ring  can- 
not positively  be  located,  as  is  the  case  frequently  in  large 
herniae,  deposit  the  fluid  well  up  in  the  canal,  where  the 
protrusion  first  appears. 

In  Direct  Hernia,  if  the  breach  in  the  abdominal  wall 
can  be  outlined,  deposit  the  fluid,  well  distributed,  in  the  tis- 
sues just  below  this  point.  As  no  canal  can  be  determined 
in  this  form  of  hernia,  it  usually  makes  its  first  appearance 
at  the  external  ring,  and  when  the  location  of  the  breach 
cannot  be  determined,  deposit  the  fluid  just  inside  of  the 
external  ring.  More  judgment  is  necessary  to  treat  this 
variety  of  hernia  than  any  other,  as  no  two  cases  are  exactly 
alike.  Bear  in  mind  the  principles  of  the  treatment ;  to 
cause  adhesions  between  the  tissues  through  which  the  in- 
testines escape,  and  deposit  the  fluid  accordingly. 

In  all  cases,  begin  the  treatment  at  the  highest  point  that 
shows  weakness.  If  this  rule  is  not  followed,  the  lower 
portion  of  the  canal  or  course  of  the  hernia  will  become 
closed  and  cannot  be  invaginated,  thus  rendering  further 
treatment  impossible.  As  the  upper  portion  closes,  make  the 
injections  lower  down. 


HERNIA.  125 

Femoral  Hernia.  The  injection  treatment  of  hernia 
was  first  only  advocated  as  a  cure  for  Oblique  or  Direct 
Hernia.,  but  its  well  known  principle  has  been  successfully 
applied  to  the  treatment  of  Femoral  Hernia,  also.  Accurate 
instructions  for  treating  this  variety  cannot  easily  be  given, 
as  the  characteristic  features  of  different  cases  vary.  Any- 
one who  has  had  experience  in  treating  other  forms,  and 
who  will  exercise  judgment,  will  be  able  to  treat  these  cases 
by  following  the  lines  of  the  general  principles  of  the  method, 
making  the  injections  always  close  to  the  point  at  which  the 
protrusion  first  appears,  and  gradually  closing  the  femoral 
canal  through  which  it  descends.  Retention,  is  of  course, 
essential. 

Umbilical  Hernia.  In  this  form  of  hernia  no  canal 
exists.  A  breach  in  the  abdominal  wall,  in  the  vicinity  of 
the  umbilicus,  allowing  the  protrusion  to  escape.  Sometimes 
it  burrows  under  the  skin  and  descends  to  some  extent.  A 
cure  of  this  form  of  hernia  necessarily  implies  an  approxi- 
mation and  connection  of  the  edges  of  the  breach,  a  process 
impossible  without  surgical  interference.  Some  of  these 
cases  can,  however,  be  relieved  to  some  extent,  by  the  follow- 
ing procedure :  A  hard  rubber  spring  truss  having  a  pad  large 
enough  to  suit  the  case,  with  a  button  large  enough  to  afford 
good  retention,  should  be  obtained.  Injections  should  be 
made,  two  or  three  at  each  visit,  around  the  edges  of  the 
breach,  and  repeated  as  in  other  forms  of  hernia.  By  this 
method  the  skin  and  muscles  which  are  often  detached,  can 
again  be  united,  and  the  opening  which  permits  the  hernia  to 
descend  between  them  is  thereby  closed. 

In  these  cases  there  is  usually  an  abundance  of  loose, 
flabby,  skin  and  tissue,  which  often  defeats  all  attempts  to 
improve  the  condition. 

The  operation  of  dividing  the  skin  and  bringing  the 
edges  of  the  ruptured  muscles  into  contact,  and  stitching 
them  together,  is  one  that  requires  but  little  surgical  ability, 
and  the  results  are  usually  such  that  will  warrant  it.  A  firm 
support  should  always  be  worn. 


126  HERNIA. 


THE  RAPID  METHOD  OF  CURE. 

By  repeating  injections  as  often  as  the  sensitiveness  of 
the  patient  will  allow,  any  form  of  inguinal  hernia  can  be 
cured  in  a  comparatively  short  time,  varying  from  one- 
third  to  one-half  the  time  required  by  the  regular  method. 
The  procedure  is  as  follows : 

The  patient  must  be  willing  to  desist  from  all  work  or 
exercise  for  a  period  of  from  ten  to  twenty  days,  according 
to  the  case,  and  for  the  greater  part  of  the  time  must  remain 
in  a  reclining  position. 

Repeat  the  injections  as  often  as  the  patient's  condition 
will  allow,  giving  him  to  understand  that  he  must  expect 
a  considerable  degree  of  soreness.  The  injections  are  usually 
made  every  two  or  three  days,  and  the  truss  must  be  worn 
constantly,  day  and  night.  The  pressure  thus  given  will 
keep  the  parts  in  contact  and  will  thus  cause  a  rapid  closure 
of  the  canal.  Some  cases  will  not  allow  an  injection  every 
two  days,  on  account  of  too  much  inflammation,  and  it 
should  only  be  repeated  when  the  patient  tells  you  that 
although  there  is  a  considerable  degree  of  soreness  present, 
he  will  be  able  to  stand  a  little  more.  Beyond  the  discomfort 
of  the  patient  there  will  be  no  unpleasant  features,  and  as  in 
the  regular  method,  no  danger. 

After  treatment  has  been  thus  continued  for  ten  to 
twenty  days,  according  to  the  progress  of  the  case,  the  patient 
may  resume  moderate  exercise,  still  wearing  the  truss,  and 
the  treatment  continued  as  may  be  necessary.  After  this 
period  of  treatment,  tests  may  be  made,  as  in  the  other 
method.  Before  making  the  tests,  it  is  well  to  wait  three 
or  four  days  without  an  injection,  to  allow  the  inflammation 
to  subside  and  the  adhesions  to  become  firm.  Continue  the 
treatment  as  directed  until  no  impulse  is  felt  on  coughing. 
Preliminary  tests  may  be  made  at  any  time  while  the  patient 
is  lying  down.  The  standing  test  is  the  one  referred  to  as 
deferred  until  the  inflammation  has  subsided. 


HERNIA.  127 

After  the  treatment  is  discontinued,  the  patient  should 
wear  the  truss  as  directed  in  the  regular  method,  and  dis- 
card gradually. 

In  persons  in  whom  difficulty  is  experienced  in  retaining 
the  hernia,  a  week's  treatment  by  this  method  will  usually 
result  in  success  in  this  particular,  when  the  treatment  can  be 
completed  by  the  regular  method. 

Careful  attention  to  these  directions  will  be  productive 
of  but  one  result,  a  complete  and  permanent  cure  in  all 
curable  cases.  A  little  experience  will  make  any  physician 
an  adept  in  the  application  of  the  treatment,  and  will  be 
productive  of  the  highest  degree  of  success. 

A  WORD  OF  ASSURANCE. 

If  there  is  any  one  question  asked  more  frequently  by 
physicians  who  are  interested  in  this  method  of  curing 
hernia,  than  any  other,  it  is  this :  Is  there  no  danger  of  Per- 
itonitis, Orchitis,  Cellulitis,  injuring  the  Epigastric  Artery, 
etc.?  My  answer  is  candidly  and  positively,  "No,  None 
Whatever."  Not  a  single  unfavorable  symptom  has  ever 
occurred  in  my  practice,  nor  has  any  been  reported  to  me 
by  the  many  physicians  who  have  used  my  fluids.  The 
reports  of  such  accidents  that  are  sometimes  seen  in  medical 
journals  are  the  result  either  of  an  unsafe  fluid  or  clumsy 
operating.  I  have  been  treating  hernia  seven  years,  and 
have  not  in  a  single  instance  been  called  to  account  for  pro- 
ducing more  than  a  moderately  severe  degree  of  inflamma- 
tion. As  before  mentioned,  this  will  occur  when  too  large 
doses  are  injected,  but  I  have  never  prescribed  as  much  as 
a  piece  of  ice  to  relieve  it.  My  only  advice  has  been,  "take 
a  rest  if  you  feel  like  it,  it  will  be  all  right  in  a  day  or  two." 

These  strong  inflammations  always  benefit  the  patient  a 
great  deal,  and  calling  attention  to  this  will  usually  be  suf- 
,cient  compensation  to  them  for  their  temporary  incon- 
venience. 


128  HERNIA. 


OTHER  INJECTION  FLUIDS  FOR  HERNIA. 


The  great  interest  that  is  being  manifested  on  all  sides 
in  this  successful  method  of  treating  hernia,  naturally  results 
in  a  number  of  different  compounds  being  employed  as 
agents  to  produce  the  irritation  and  inflammation  necessary 
to  effect  a  cure,  many  of  which  are  doubtless  of  value.  A 
number  of  the  better  known  formulae  will  here  be  given. 
These  have  been  obtained  from  medical  journals  and  from 
physicians  who  originated  them  and  used  them  in  their  prac- 
tice. Such  comments  as  suggest  themselves  are  appended 
thereto. 

Dr.  Souder's  Formulae. 

In  a  series  of  articles  published  by  Dr.  Souder,  the  fol- 
lowing formulae  are  given. 

Fluid  No.  i. 

1^     Zinc    Sulphate gr.  ij . 

Creasote    TTt  iij. 

Fid.  Ext.  Hamamelis. 

Glycerine aa  TT\,  xxx. 

Mix.     Inject  2  to  4  minims. 

Fluid  No.  2. 

^     Fl.  Ext.  Quercus  Alba ' .'.   fl.  §  iv. 

Reduce  by  heating  to fl.  §  j . 

Alcohol   fl.  I  j. 

Acid    Carbolic Til  ij . 

Mix.  Inject  1  to  3  minims.  Repeat  when  reaction  has 
disappeared.  This  formula  has  been  discarded  as  it  causes 
too  much  pain. 


HERNIA.  I29 

Fluid  No.  3. 

1$     Guaiacol. 

Beechwood  Creasote aa  171.  ij. 

Zinc    Sulphate gr.  ij. 

Fl.  Ext.  Hamamelis TIX  xxx. 

Glycerine    ni    xxx. 

Mix.    Inject  2  to  3  minims. 

This  fluid  is  the  same  as  No.  1,  with  the  addition  of  the 
guaiacol. 

It  is  the  formula  now  used  by  the  doctor,  and  the  one 
on  which  he  depends  in  the  majority  of  cases. 

The  Heaton  Formula. 

I£      Ext.   Quercus   Alba gr.  xiv. 

Fid.  Ext.   Quercus  Alba fl.  5  j. 

Morphia    Sulphate gr.  ij. 

Mix  and  heat  in  a  capsule  over  a  sand  bath  until  a 
homogeneous  solution  is  formed. 

Dr.  Heaton's  formula  is  sometimes  given  in  which  four 
grains  of  morphine  sulphate  are  added  to  the  above  quan- 
tity. The  quantity  injected  varies  from  five  to  fifteen  drops, 
as  may  be  required. 

After  Heaton  came  Warren,  who  employed  this  fluid. 

I£     Fl.  Ext.  Quercus  Alba %  viij. 

Reduce  to  §  ij  by  heat. 

Alcohol,   90  % 3  vi. 

Ether   Sulphuric 3  iv. 

Morphine  Sulphate gr.  iv_ 

Mix.  Inject  15  to  20  minims  in  small  and  recent  her- 
niae,  and  25  to  50  minims  in  large  or  old  herniae. 

"This  fluid  will  cause  a  marked  reduction  of  pulse  and 
temperature,  and  it  may  be  necessary  to  put  a  hot  water  bot- 


I'30  HERNIA. 

tie  to  the  patient's  feet.  This  reduction  may  last  as  long  as 
forty-eight  hours  and  give  a  decided  advantage  in  obtaining 
a  more  local  effect  of  the  irritant."  Dr.  Souder  used  this 
combination  on  six  patients  and  all  suffered  intense  pain  for 
days  thereafter.  The  use  of  a  fluid  that  causes  such  disas- 
trous results  is  entirely  unwarranted. 

The  Fidelity  Fluid.  I  have  on  several  occasions  seen 
this  fluid  stated  to  be  Fluid  Extract  of  Ergot.  Any  physi- 
cian who  has  ever  seen  this  fluid,  could  not  possibly  make 
this  assertion.  It  is  no  more  ergot  than  tincture  of  green 
soap.  The  following  formula  was  given  me  by  a  physician 
who  obtained  it  from  one  of  the  operators  of  the  company, 
with  the  assurance  that  it  is  the  correct  formula.  When 
compounded,  it  makes  a  fluid  identical  in  appearance  and 
odor,  with  the  genuine. 

I£     Acid    Carbolic 95   % 

Glycerine. 

Alcohol    aa  p.  e. 

Tr.   Iodine q.   s.   to   color 

to  the  color  of  sherry  wine. 

Dr.  Walking's  Fluid. 

This  fluid  is  one  of  those  for  which  the  formula  is  given 
in  such  a  manner  that  it  cannot  be  prepared  without  further 
instructions. 

1^      Complex  Salts  of  Aldehyde 30  % 

Iodo-ethylate  of  Guaiacol 30  % 

Sulpho-tannate   of   Zinc 20  % 

Free   Guaiacol 5  % 

Beech  wood    Creasote 15   % 

The  following  note  follows  the  formula :  "These  rare 
and  expensive  chemicals  are  separately  prepared  and  then 
combined  in  strict  conformity  with  their  respective  affinities 
and  dosage,  and  dissolved  in  an  antiseptic  medium." 


HERNIA.  131 

Dr.  Robinson's  Fluid. 

I>     Acid  Carbolic,  95  % fl.  3  ij. 

Glycerine,  C.  P fl.  5  iv. 

Tr.  Iodine,  U.  S.  P fl.  3  ij. 

Potassium   Permanganate 5  j . 

Caramel    gr.  xv. 

"Mix.  First  add  the  glycerine  to  the  carbolic  acid,  after 
which  add  the  iodine  and  caramel,  and  then  the  potassium 
salt  in  crystals.  Allow  it  to  stand  for  about  three  weeks, 
shaking  daily.  At  the  end  of  this  time  it  is  ready  for  use. 
Inject  eight  drops  at  a  time." 

In  this  formula  two  points  that  are  neither  pharma- 
ceutically  correct  not  therapeutically  indicated,  stand  out  so 
prominently  that  they  demand  criticism.  The  first  is,  the 
addition  of  potassium  permanganate  to  an  organic  compound. 
This  salt  of  potassium  is  such  a  strong  oxidizing  agent  that 
it  undoubtedly  impairs  the  value  of  an  otherwise  plausible 
formula.  The  second  is,  the  addition  of  caramel.  What  indi- 
cation is  met  by  the  addition  of  burnt  sugar  to  a  formula  for 
this  purpose  is  more  than  can  be  imagined.  Caramel  is  used 
for  only  one  purpose  in  pharmacy,  as  a  coloring  agent.  The 
color  of  a  hernial  fluid  is  certainly  immaterial  to  its  effect. 
Giving  the  dose  in  drops  is  also  faulty. 

O.  E.  Miller's  External  Astringent.  The  O.  E.  Mil- 
ler Hernia  Cure  Company  were  among  the  first  to  revive  this 
method,  some  ten  or  fifteen  years  ago.  Their  injection  fluid 
was  the  same  as  the  Heaton  formula,  while  externally  they 
used  a  preparation  known  as  "External  Astringent."  It  was 
given  to  the  patient  for  use  every  night.  The  formula  was 
furnished  by  a  physician  who  conducted  one  of  the  offices  of 
the  company.    He  states  that  he  "made  gallons  of  it." 

External   Astringent. 
1^     Tr.  Iodine  Comp. 

Soap    Liniment aa  p.  e. 

Mix.     On  standing  for  a  week  or  two,  with  frequent 


132  HERNIA. 

shaking,  this  mixture  loses  its  iodine  color  and  becomes  a 
clear  fluid  at  the  bottom  with  the  oily  substance  in  the  lini- 
ment at  the  top.  When  shaken,  it  becomes  milky  in  appear- 
ance. 

Dr.  Provost's  Fluid. 

^     Guaiacol,   pure n\  xxx. 

Zinc    Sulphocarbolate gr.  x. 

Creasote,    Beechwood Tl\  xxx. 

Glycerite  of  Tannin q.  s.  ad.  fl.  5  j. 

Mix.  Reduce  10  to  50  %  with  alcohol  and  inject  four 
or  five  drops  of  the  weakest  solution,  gradually  increasing 
to  twelve  drops.  Increase  strength  of  solution  according  to 
reaction. 

There  are  hundreds  of  other  formulae  floating  about 
medical  journals,  many  of  which  are  similar  to  those  already 
given,  while  others  do  not  commend  themselves  sufficiently 
to  give  them  room.  With  this  collection  of  formulae,  there 
is  surely  no  necessity  to  wish  for  any  more.  A  few  others 
are  however  given  under  "Secret  Systems  Exposed." 


TRUSSES.  133 

TRUSSES. 

No  matter  how  thoroughly  the  subject  is  understood;  no 
matter  how  carefully  the  treatment  is  given ;  no  matter  how 
much  is  claimed  for  the  injection  fluid  used,  hernia  cannot 
be  cured  by  the  injection  method  unless  the  ,  patient  is 
properly  fitted  with  a  suitable  truss.  Three-fourths  of  the 
unsuccessful  or  unsatisfactory  results  following  this  treat- 
ment can  be  directly  traced  to  lack  of  attention  to  this 
important  detail. 

Fully  one-half  of  the  trusses  in  daily  use  do  not  fit  the 
persons  wearing  them.  Careful  observation  is  the  basis  of 
this  assertion,  and  it  can  be  verified  by  anyone  desiring  to 
do  so. 

This  condition  of  affairs  is  due  to  several  causes ;  the 
chief  of  which  is  the  general  custom  of  physicians  to  refer 
their  ruptured  patients  to  instrument  dealers  and  druggists, 
many  of  whom  are  no  more  capable  of  fitting  a  truss  to  a 
person  properly,  than  they  are  to  perform  the  operation  for 
the  radical  cure.  Another  cause  is  due  to  an  unaccountable 
idea  that  some  ruptured  persons  have,  that  hernia  is  an 
evidence  of  loose  morals  or  that  it  is  due  to  some  immoral 
action  on  their  part.  This  portion  are  unwilling  to  purchase 
a  truss  personally,  but  order  one  by  mail  and  simply  wear  it, 
whether  it  fits  or  not. 

Mail  order  houses  advertise  trusses ;  department  stores 
sell  them  over  the  counter  and  fakirs  carry  them  through 
the  country.  In  the  majority  of  instances  the  "fitting"  is 
done  by  the  person  who  intends  to  wear  it.  I  am  not  one 
who  would  make  the  claim  that  none  but  a  physician  can 
properly  fit  a  truss,  for  any  intelligent  person  can  in  a 
reasonably  short  time  become  proficient  in  the  art  if  he 
applies  himself,  but  how  often  is  this  done?  The  principal 
idea  is  to  sell  the  truss,  and  if  it  does  not  fit,  sell  another 
one.  Being  a  physician  does  not  necessarily  imply  that  one 
can  fit  a  truss  properly,  for  unless  some  attention  has  been 


1 34  TRUSSES. 

given  to  the  subject,  the  degree  of  "M.  D."  carries  with  it 
no  guarantee  whatever. 

WHY  TRUSSES  FAIL. 

Trusses  fail  to  retain  the  protrusion  properly  for  various 
reasons.  It  ma)'  cause  pain  to  the  wearer,  necessitating  a 
frequent  shifting  of  the  offending  parts,  thus  permitting  the 
hernia  to  protrude  more  or  less,  with  corresponding  irrita- 
tion. 

It  may  fail  to  retain  the  hernia  on  account  of  being  of 
improper  size,  or  the  adjustment  may  be  faulty. 

The  pad  may  be  too  small  and  practically  enter  the 
opening  and  allow  the  hernia  to  protrude  on  the  side  of  it. 
The  French  truss,  with  its  strong  spring  of  steel  and  a  small 
convex  pad  is  particularly  apt  to  be  faulty  in  this  respect. 

The  pad  may  be  too  large  and  cause  undue  pressure  on 
other  parts,  principally  the  cord,  and  cause  hydrocele  of  the 
cord ;  or  on  the  arteries  and  interfere  with  the  nutrition  of 
the  testicle. 

The  pad  may  rest  on  the  external  ring  and  allow  an 
incomplete  hernia  behind  it. 

SELECTION  OF  PAD. 

The  shape  of  the  pad  should  conform  to  the  nature  and 
size  of  the  opening.  Whether  round  or  oval,  I  prefer  either 
a  flat,  slightly  convex  or  full  convex  pad.  I  have  never  been 
able  to  see  any  advantage  in  the  concave  pad,  as  recom- 
mended by  some,  nor  with  the  pneumatic  collar  around  the 
edge  of  the  pad.  The  flat  pad  is  less  satisfactory  than  the 
convex,  yet  in  certain  cases  of  direct  hernia,  I  have  found  this 
shape  quite  satisfactory.  The  selection  of  the  properly 
shaped  pad  is  a  matter  upon  which  a  considerable  amount  of 
good  judgment  can  be  exercised  to  advantage.  Explicit 
directions  to  suit  every  case  cannot  be  reasonably  expected, 
yet  I  will  endeavor  to  mention  some  of  the  leading  indica- 
tions, which  may  be  borne  in  mind. 

In  case  a  hernia  is  difficult  to  retain,  even  when  properly 


TRUSSES.  135 

fitted,  and  consequently  requires  a  strong  spring,  a  pad 
should  be  selected  that  is  not  too  hard.  In  these  cases  a  cellu- 
loid, hard  rubber  or  uncovered  wood  pad  will  probably 
irritate.  A  spring  pad  covered  with  soft  kid  or  chamois, 
or  a  water  pad  is  best  suited  for  this  class  of  hernia. 

Persons  employed  at  trades  that  soil  the  clothing  and 
body,  such  as  machinists,  moulders,  mill-workers,  miners, 
etc.,  should,  if  possible,  be  supplied  with  either  a  wood, 
rubber  or  celluloid  pad,  .for  which  a  home-made  covering 
can  be  made,  which  can  be  thrown  away  when  soiled.  The 
spring  or  water  pads  can  be  similarly  protected  if  the  harder 
pads  cause  annoyance.  In  this  manner  the  pads  can  be  kept 
clean  and  their  usefulness   extended. 

Size  of  Pads.  When  the  Hernia  is  small  and  not  hard 
to  retain,  a  pad  should  be  selected  that  is  large  enough  to 
furnish  good  marginal  pressure,  so  as  to  avoid  its  entrance 
through  the  opening  and  aggravate  the  hernia.  This  does 
not  necessarily  call  for  a  large  pad,  but  one  just  large  enough 
to  accomplish  its  purpose.  As  the  protrusion  is  slight  it 
requires  no  more  than  the  ordinary  convexity. 

In  the  large  majority  of  cases  no  particular  attention 
need  be  paid  to  the  size  of  the  pad  used,  as  the  pad  usually 
supplied  with  standard  trusses  meets  the  necessary  require- 
ments. It  is  only  in  the  larger  herniae,  when  the  regular 
pads  prove  insufficient,  that  a  special  pad  will  be  called  for. 
The  automatic  spring  pad,  fitted  with  an  oval  collar  of  leather 
covered  rubber,  and  a  separate  oblong  hard  rubber  pad  in 
the  center,  which  adjusts  itself  automatically  to  different 
degrees  of  pressure  by  means  of  an  internal  coil  spring  on 
which  it  is  mounted,  is  perhaps  the  most  desirable  pad  for 
general  use. 

In  unusual  cases,  a  good  rule  to  remember  is :  The 
larger  the  breach  in  the  abdominal  walls,  the  larger  and 
more  convex  should  be  the  pad.  A  large  opening  is  always 
indicated  by  the  freedom  with  which  the  hernia  descends, 
or  the  forcible  and  prompt  impulse. 


136  TRUSSES. 

I  have  frequently  been  able  to  furnish  complete  and 
perfect  retention  by  the  use  of  a  double  elastic  truss,  worn 
for  a  single  hernia,  and  fitted  with  only  one  pad.  The 
strong  leather  support  with  which  double  trusses  of  this 
kind  are  equipped  being  just  the  proper  support. 

Persons  with  thin  abdominal  walls  do  not  require  as 
much  convexity  of  pad  as  those  who  are  stout  and  fatty  in 
those  parts,  but  unless  in  the  latter  cases,  no  distinction  is 
made. 

The  prevention  of  chafing  is  frequently  a  point  that 
requires  attention,  although  with  the  form  of  truss  that  I 
have  used  most  frequently,  this  annoyance  is  reduced  to  the 
minimum.  The  proper  adjustment  of  the  wire  spring  which 
can  be  easily  bent  and  made  to  conform  with  the  curves  of 
the  body,  is  the  first  essential,  and  the  other  is  to  keep  the 
pads  firm  in  their  proper  position  by  the  proper  adjustment 
of  the  bands. 

The  regular  equipment  of  trusses,  according  to  order, 
will  in  most  cases  prove  satisfactory  if  properly  adjusted. 
It  is  only  in  the  unusual  cases  that  special  equipment  is 
required,  and  it  is  these  that  often  tax  the  ingenuity  of  the 
best  and  most  expert  fitters. 


CANCER.  137 


CANCER. 


True  Cancer;  An   Epithelial,  Neoplasm. 

For  some  unknown  reason  the  treatment  of  epithelioma 
by  the  application  of  caustics  and  other  local  applications, 
has  for  many  years  past  remained,  with  a  few  notable  excep- 
tions, in  the  hands  of  irregular,  non-graduate  and  ignorant 
practitioners.  Persons  without  a  trace  of  education  or  in- 
formation on  any  other  subject,  and  not  infrequently  with 
but  a  superficial  knowledge  of  cancer  and  its  treatment,  have 
nevertheless  so  persistently  and  I  may  say,  so  successfully 
used  this  method  of  treatment,  that  it  is  to-day  known  in 
every  village  and  hamlet  of  this  and  other  countries,  and  is 
at  last  receiving  recognition  by  college  professors,  and  is 
indeed  being  taught  in  some  modern  schools  of  medicine.  It 
is  to  be  hoped  that  this  treatment  will  commend  itself  to  all 
progressive  physicians  and  that  by  its  intelligent  use  we  may 
obtain  even  more  information  of  a  positive  nature  in  regard 
to  the  cause,  the  painless  treatment  and  the  absolute  cure  of 
this  interesting  disease. 

Etiology. 

In  regard  to  the  etiology  of  cancer  much  has  been 
written  but  little  is  known.  That  its  primary  cause  is  an  ir- 
ritant admits  of  no  doubt,  but  what  the  nature  of  the  irritant 
that  causes  the  local  new  growth  of  the  epithelial  cells  may 
be,  we  know  no  more  now  than  was  known  half  a  century 
ago  when  its  pathology  was  demonstrated.  The  untiring 
and  often  heard  of  searcher  for  microbes  has  at  least  a  dozen 
times  proclaimed  to  the  world  that  at  last  he  has  discovered 
the  varmint,  and  that  henceforth  all  that  will  be  necessary  to 
cure  cancer  will  be  to  locate  and  exterminate  him,  but  all  of 


I38  CANCER. 

these  discoveries  have  faded  into  the  mere  suspicion  of  an 
idea,  in  the  light  of  unbiased,  careful  and  intelligent  investi- 
gation. That  the  primary  cause  of  cancer  will  sooner  or 
later  be  discovered,  cannot  be  doubted,  but  until  then,  the 
less  said  the  better.  Other  and  more  essential  points  will 
therefore  be  taken  up  and  dwelt  upon;  predisposing  causes, 
pathology,  diagnosis  and  treatment. 

Age. 

From  the  observation  of  physicians  who  have  made  the 
study  and  treatment  of  cancer  a  specialty,  we  have  abundant 
proof  that  the  majority  of  cases  of  cancer  are  found  in  the 
aged.  This  leads  us  to  believe  that  the  senile  changes  which 
take  place  in  the  tissues  and  epithelium  with  advancing 
years  have  some  relation  to  the  growth  of  the  neoplasms 
under  consideration,  but  further  than  this  nothing  can  be 
said  with  certainty. 

Heredity. 

Not  infrequently  do  we  find  that  cancer  occurs  more 
frequently  in  families  in  which  it  has  once  appeared,  although 
persons  not  related,  but  occupying  the  same  residence,  have 
been  known  to  develop  cancer  in  succession,  thus  rendering 
it  necessary  for  us  to  consider  the  liability  of  direct  conta- 
gion, as  cancer  is  undoubtedly  capable  of  being  transmitted 
by  contact.  Thus  when  it  occurs  successively  in  families, 
each  and  all  using  the  same  linens,  dishes,  utensils  or  imple- 
ments, heredity  cannot  be  said  to  be  entirely  substantiated. 

Locality. 

The  frequency  with  which  cancer  occurs  in  a  portion  of 
several  states  in  the  central  part  of  the  United  States,  has 
given  that  locality  the  name  of  "The  Cancer  Belt,"  but  as  in 
other  instances,  we  cannot  explain  the  relation  which  climate, 
soil  or  location  bears  to  the  primary  cause  of  the  disease. 


CANCER.  I39 

Traumatic  Causes. 

A  popular  idea  obtains  that  cancer  will  result  from  trau- 
matic or  constantly  irritating  causes,  (and  this  is  in  fact  in 
line  with  the  best  information  we  have,  even  though  the 
nature  of  the  necessary  irritant  is  unknown,)  and  it  is  very 
commonly  supported  by  indisputable  facts.  Its  frequency  on 
the  lips  or  tongue  of  the  pipe  smoker,  particularly  the  short 
stemmed  one;  on  the  cervix  of  the  uterus  after  laceration; 
or  appearing  after  warts  or  other  cutaneous  growths  have 
been  irritated  or  forcibly  removed,  can  surely  not  be  satis- 
factorily explained  by  terming  it  a  coincidence. 

Numerous  other  and  largely  theoretical  causes  have  at 
various  times  been  brought  forward,  but  which  have  never 
been  accepted  as  feasible.  Among  the  most  notable  may  be 
mentioned  the  theory  of  Cohnheim,  in  which  he  claims  that 
cancer  is  caused  by  the  stimulation,  late  in  life,  of  cells  which 
have  retained  their  embryonic  condition,  and  the  parasitic 
protoplasmic  body  found  in  cancerous  growths  by  Foa  and 
Plimmer,  but  which  proved  to  be  degenerate  products  of  the 
disease  instead  of  its  cause. 

Pathological  Observations. 

The  term  Cancer,  like  Dyspepsia  and  Catarrh,  is  one 
that  is  much  misused.  Prior  to  the  pathological  demonstra- 
tions of  malignant  growths,  after  which  they  were  classified 
and  re-named,  all  malignant  growths  were  termed  Cancer. 
Cancer,  strictly  speaking,  is  always  an  epithelial  neoplasm; 
a  new  growth  of  epithelial  cells,  although  in  its  progress  and 
growth  more  or  less  connective  tissue  is  included.  In  struc- 
ture these  growths  are  composed  of  pegs  or  columns  of  cells, 
which  infiltrate  first  into  the  connective  tissues  and  later  into 
the  underlying  structures  even  including  bones.  The  epi- 
thelial ingrowths  contain  globular  masses  of  flattened  cells, 
the  so-called  cell  nests  or  epidermic  pearls,  while  the  sur- 
rounding fibrous  stroma  is  usually  infiltrated  with  small 
cells.  When  the  quantity  of  connective  tissue  included  in 
the  growth  is  large,  the  growth  will  be  relatively  more  solid 


I4O  CANCER. 

and  firm.  The  growths  that  are  softer  are  usually  of  more 
rapid  growth  and  do  not  contain  as  much  connective  tissue. 
As  text  books  on  the  subject  of  pathology  are  convenient 
to  all  practitioners  it  will  be  unnecessary  to  cover  this  point 
to  any  greater  extent,  and  we  will  pass  on  to  two  more 
essential  points,  Diagnosis  and  Treatment. 

Diagnosis. 
Any  cutaneous  or  mucous  surface  covered  with  squam- 
ous epithelium  may  be  attacked  by  cancer.  When  the  dis- 
ease attacks  the  skin,  the  parts  most  commonly  involved 
are  the  nose,  lip,  penis,  scrotum,  vulva,  or  the  anus.  The 
mucous  surfaces  most  commonly  involved  are  those  of  the 
tongue,  gums,  palate,  larynx,  alimentary  canal,  bladder,  os 
uteri  or  in  fact  any  organ  or  part  thereof  which  is  composed 
of  epithelial  cells. 

Varieties. 
Three  distinct  varieties  of  epithelioma  are  met  with : 
The  Superficial,  Deep-seated  and  Papillomatous. 

The  Superficial  Variety 
is  sometimes  known  as  Discoid  Epithelioma  or  Rodent  Ulcer. 
As  its  name  indicates  it  begins  and  exists  for  some  time,  as 
a  flat,  superficial,  firm,  reddish  or  yellowish  tubercle,  or  an 
aggregation  of  such,  as  a  warty  excrescence  or  a  localized 
degenerative  patch.  Sooner  or  later,  sometimes  after  months 
or  years,  the  surface  becomes  excoriated  and  a  yellowish  or 
brownish  crust  appears.  This  excoriation  gradually  spreads 
and  develops  into  a  superficial  ulceration  which  slowly  in- 
creases in  size.  The  ulcer  usually  has  an  uneven  cauliflower- 
like appearance,  base  and  margins  indurating,  but  with  no 
evidence  of  surrounding  inflammation,  secretes  a  thin  watery 
fluid  which  dries  into  a  firm  adherent  crust,  and  obstinately 
resists  the  action  of  such  treatment  as  usually  cures  common 
ulcers  and  sores.  When  the  nearest  lymphatic  glands  are 
enlarged  the  diagnosis  is  practically  certain.  The  general 
health  usually  remains  as  usual  and  the  presence  of  a  super- 
ficial epithelioma  may  cause  but  little  trouble,  unless,  as  fre- 
quently is  the  case,  it  develops  into  the  deep-seated  variety. 


CANCER.  141 

The  Deep-seated  Variety. 

may  develop  from  the  superficial  form  or  may  begin  as  a 
tubercle  or  nodule  in  the  skin.  A  typical  growth  of  this 
nature  will  appear  as  a  reddish,  waxy,  shining  tubercle  or 
nodule,  highly  vascularized  and  more  deeply  seated  than  the 
former  variety.  Deep-seated  ulceration  takes  place  which 
enlarges  in  all  directions,  the  edges  being  everted  as  a  rule, 
with  an  atrophic  center  which  increases  in  depth  and  invades 
muscle,  cartilage  and  bone.  It  bleeds  easily  and  gives  rise  to 
considerable  burning  pain.  Its  secretion  is  a  scanty,  pale  yel- 
lowish purulent  fluid  of  a  decidedly  foul  and  decaying  odor. 
The  neighboring  lymphatics  always  enlarge  and  fre- 
quently break  down  and  suppurate.  If  left  alone  it  pursues 
a  progressive  course  and  death  eventually  ensues  from  in- 
anition, septicaemia,  hemorrhage,  or  involvement  of  the  vital 
parts. 

The  Papillomatous  Variety. 

is  usually  a  last  stage  of  either  of  the  other  two  forms  or  may- 
begin  independently  as  a  papillary  or  warty  growth.  It  pre- 
sents an  ulcerated,  fissured  and  papillomatous  surface,  bright 
florid  color,  is  very  vascular  and  bleeds  easiiy.  Pain  is 
usually  present  in  a  greater  or  lesser  degree.  It  discharges 
a  dirty  looking,  foul,  viscid,  irritating  fluid  which  dries  into 
crusts.  Lymphatic  glands  are  involved  and  frequently  break 
down.    It  terminates  in  death  from  sapremia  or  exhaustion. 

The  form  of  cancer  that  is  known  as  Carcinoma  Cutis, 
while  a  superficial  growth,  and  liable  to  occur  as  a  primary 
affection,  is  but  seldom  met  with  as  such,  but  more  fre- 
quently is  secondary  to  cancer  of  the  female  breast  or  of  the 
internal  organs,  and  is  therefore  largely  without  the  domain 
of  treatment  by  this  method.  Paget's  disease  of  the  nipple 
has  also  recently  been  classed  among  these  growths, 
although  it  resembles  eczema  very  much,  and  has  been 
termed  an  eczematoid  epitheliomatosis. 

The  diagnosis  of  cancer  of  the  skin  is  to  be  differentia- 
ted from  the  following:  from  syphilis  by  the  history,  dura- 


142  CANCER. 

tion,  character  of  the  base  and  edges,  slow  progress,  charac- 
ter of  the  discharge  and  in  doubtful  cases  by  treating  for 
syphilis  as  a  therapeutic  test;  from  warts  or  warty  growths 
it  can  be  differentiated  by  the  discharge  and  tendency  to 
crusting,  break  down  and  ulcerate;  from  lupus  by  the  pecu- 
liar and  multiple  deposits  of  this  disease,  the  tendency  to 
scar  formation  and  its  frequent  beginning  in  early  life. 

TREATMENT  OF  CANCER. 

Cancer  Specialists  have  always  claimed  and  attempted 
more  than  they  could  reasonably  expect  from  the  caustic 
treatment,  and  it  is  on  this  account  that  this  eminently  suc- 
cessful method  of  treatment  has  not  received  the  recognition 
which  it  so  richly  merits,  if  indeed  it  has  not  been  respon- 
sible for  the  disrepute  in  which  it  is  held  by  many  physicians. 

The  caustic  treatment  of  cancer  is  applicable  to  all 
varieties  of  epithelial  neoplasms,  providing  their  anatomical 
location  is  not  such  as  to  preclude  the  practicability  of  apply- 
ing the  same.  It  is  not  applicable  and  should  not  be  em- 
ployed in  malignant  growths  of  great  size,  or  which  involve 
the  vital  parts,  the  removal  of  which  could  only  be  accom- 
plished at  an  unwarrantable  risk  to  the  patient  and  profes- 
sional reputation.  It  is  the  indiscriminate  application  of 
this  method  that  is  accountable  for  the  lack  of  confidence  in 
it  which  is  so  apparent  on  all  sides. 

In  properly  selected  cases,  intelligently  and  carefully 
applied,  the  caustic  method  of  treating  cancer  will  effect  a 
large  percentage  of  cures,  and  has  the  advantage  of  appeal- 
ing to  persons  who  justly  dread  the  knife,  produces  no  shock, 
requires  no  anesthetic,  is  free  from  danger,  often  causes  but 
trifling  pain  and  is  highly  remunerative  to  the  practitioner. 

Cancer  of  the  skin  or  mucous  membrane,  being  a  local 
disease  except  in  its  last  stages,  can  be  cured  by  local  treat- 
ment, although  in  many  cases  a  constitutional  remedy  is 
advantageous  as  a  corrective  of  any  systemic  disease  which 
may  be  present  and  possibly  have  an  influence  upon  the 
growth. 


CANCER.  143 

There  is  ground  for  the  belief  that  certain  drugs  exert 
a  beneficial  influence  over  malignant  growths,  even  though 
their  action  cannot  in  all  cases  be  depended  upon.  In  cases 
in  which  the  disease  spreads  slowly  and  in  which  there  is  no 
immediate  danger  to  be  feared  by  delaying  active  treatment, 
internal  medication  will  at  least  do  no  harm. 

Arsenic 
is  probably  the  principal  remedy  that  has  been  advocated  as 
a  constitutional  remedy  for  cancer,  being  recommended  by 
Lassar,  who  however  also  used  in  connection  with  it  a  paste 
known  as  Lassar's  paste,  formula  of  which  is  given  later. 

Cheudonium   Majus. 
is  recommended  by  a  number  of  physicians  who  have  devoted 
considerable  time  to  the  study  and  treatment  of  cancer,  and 
it  is  still  under  observation. 

While  not  willing  to  assert  that  this  drug  will  ever  be- 
come a  recognized  remedy,  constitutionally,  for  cancer,  it 
is  encouraging  to  be  able  to  state  that  the  opponents  of 
constitutional  treatment  are  not  yet  willing  to  assert  that  it 
does  not  benefit  certain  forms  of  the  disease. 

LOCAL  TREATMENT  is  the  only  method  at  present 
perfected  upon  which  we  can  place  dependence,  and  of  this 
there  are  several  forms. 

The  surgeon  will  naturally  find  recourse  to  the  knife 
and  claim  that  excision  is  the  only  means  of  cure.  How  un- 
certain and  unsatisfactory  this  treatment  is,  is  too  well 
known  to  be  entitled  to  further  comment. 

Let  it  suffice  to  say  that  no  human  power  can  ascertain 
the  degree  of  infiltration  that  has  taken  place,  and  when 
these  growths  are  thus  removed  there  is  nothing  to  guide 
the  operator  as  to  the  amount  of  tissue  he  shall  remove, 
and  he  either  removes  too  little  and  thus  allows  some  of  the 
neoplasm  to  remain  to  again  develop,  or  he  removes  more 
than  is  necessary  and  thereby  subjects  the  patient  to  risk, 
excessive  shock  and  subsequent  disfigurement. 


144  CANCER. 

The  Thermo-Cautery  and  Galvanism 
have  their  advocates,  but  this  method  is  open  to  the  same 
objection  as  excision,  as  the  operator  cannot  differentiate 
between  healthy  and  diseased  tissue. 

The  X-Rays. 

Judging  from  the  amount  of  space  given  to  articles  in 
medical  journals  on  the  treatment  of  epithelioma  and  other 
malignant  growths  by  means  of  the  X  Rays,  there  would  be 
some  ground  for  the  belief  that  much  good  can  be  accom- 
plished by  this  new  treatment.  It  is  a  subject  too  extensive 
for  consideration  here,  and  attention  is  merely  directed  to- 
ward it. 

Alcohol 

injected  in  and  around  cancerous  growths,  seems  to  exert  a 
good  influence  over  these  growths  and  many  cures  are  re- 
ported. 35  to  50  %  solutions  are  injected  into  the  surround- 
ing tissues. 

CAUSTIC  REMEDIES. 

As  a  softening  agent  and  for  the  removal  of  the  super- 
ficial layers  of  epithelium,  Salicylic  Acid  is  a  valuable  agent. 
It  may  be  employed  either  pure  or  in  a  mixture  with  starch, 
in  powder  form,  or  as  an  unguent,  prepared  with  vaseline.  If 
this  is  not  used  as  a  preliminary,  the  surface  of  the  cancer 
should  be  scraped  with  a  curette  until  slight  bleeding  occurs. 
After  this  has  ceased  the  caustic  can  be  applied. 

Nitrate  of  Silver 

has  frequently  been  mentioned  as  a  caustic  for  the  treatment 
of  cancer  but  its  action  is  too  superficial  and  does  not  destroy 
the  deeper  structures,  in  fact  it  frequently  rather  stimulates 
the  growth  than  retards  it.    It  is  of  no  value. 

Lactic  Acid 

is  a  remedy  that  does  not  attack  normal  tissues  but  it  is  at  best 
only  a  feeble  caustic  and  is  not  by  any  means  reliable. 


CANCER.  I45 

Sulphuric  Acid 

is  recommended  by  some  but  it  has  the  disadvantage  of 
destroying  healthy  and  diseased  tissue  alike,  an  undesirable 
feature.     It  is  also  extremely  painful. 

Nitric  Acid 

is  better  and  superficial  growths  have  often  been  success- 
fully removed  by  its  use.  It  should  be  applied  with  a  glass 
rod. 

Pyrogaluc  Acid 

has  been  much  used  and  with  considerable  success.  It  is 
best  adapted  to  superficial  growths.  It  may  be  applied  in 
powder  form  or  in  the  form  of  an  ointment  with  lard,  in 
strength  of  twenty-five  to  seventy-five  per  cent.  Curetting 
of  the  surface  should  precede  its  application.  It  is  but 
slightly  painful  and  does  not  attack  healthy  tissue.  An  ap- 
plication, when  made,  should  be  allowed  to  remain  for  a 
week  or  more  and  a  fresh  one  applied  until  the  desired 
result  is  obtained.  It  is  of  no  value  in  deep  seated  and 
largely  infiltrated  growths. 

Chloride  oe  Zinc. 

This  is  one  of  our  best  remedies  and  one  which  has 
been  advocated  for  many  years.  It  is  effective  without  a 
doubt  and  produces  a  clean  slough  and  there  is  no  danger  of 
constitutional  poisoning.  It  is  not  the  least  painful  remedy 
that  can  be  employed  but  its  curative  action  admits  of  no 
doubt. 

Caustic  Potash 
is  especially  adapted  to  use  when  cancer  involves  or  appears 
on  mucous  surfaces.  It  is  best  applied  in  liquid  form  by 
means  of  a  glass  rod,  following  its  application  immediately 
with  one  of  dilute  acetic  acid.  A  slough  forms,  which  ex- 
tends into  the  healthy  tissue,  but  leaves  a  clean  healthy 
ulceration  which  heals  without  difficulty. 


I46  CANCER. 

Arsenious  Acid. 

In  arsenic  we  have  the  best  caustic  with  which  we  are  at 
present  familiar.  It  is  applicable  to  all  cases  of  cutaneous 
cancer,  whether  superficial  or  deep.  Its  action  is  not  severely 
painful  and  can  usually  be  borne  without  any  or  only  small 
quantities  of  opiates.  Its  action  is  strictly  selective,  in  that 
it  acts  only  on  the  carcinomatous  growth,  never  attacking 
or  damaging  healthy  tissue,  and  seems  to  exert  the  proper 
degree  of  caustic  action  needed  for  the  destruction  of  the 
growth.  It  is  never  absorbed  although  used  in  large  quanti- 
ties and  over  large  surfaces. 

The  remaining  scar  is  usually  insignificant  and  if  the 
growth  removed  was  small  it  is  frequently  impossible  to  lo- 
cate the  site  thereof  a  short  time  afterward.  The  surface  of 
the  growth  should  always  be  curetted  before  applying  arse- 
nic as  its  action  on  unbroken  skin  is  slow  and  tedious. 
When  the  growth  to  be  removed  is  larger  than  four  square 
inches  it  is  advisable  to  treat  only  part  of  it  at  one  time,  in 
order  to  limit  the  inflammatory  reaction  which  results.  The 
application  of  the  caustic  should  always  extend  at  least  one- 
half  to  one  inch  over  the  healthy  tissue  as  infiltration  usually 
extends  that  distance  into  it. 

The  surrounding  tissues  will  swell  considerably  during 
the  action  of  the  caustic,  but  this  need  cause  no  concern 
whatever,  as  it  will  subside  in  a  day  or  two.  Should  the  eye 
be  closed  by  swelling,  when  treatment  is  applied  to  the  face, 
no  alarm  need  be  felt.  The  eye  will  not  be  injured.  It  is 
also  well  to  bear  in  mind  that  as  infiltration  always  extends 
into  the  healthy  tissues  for  some  distance,  that  the  slough 
that  will  be  loosened  will  be  considerably  larger  than  the 
original  growth.  No  healthy  tissue  will  however  be  re- 
moved and  healing  of  the  ulceration  usually  proceeds  unin- 
terruptedly under  ordinary  care.  Regarding  the  treatment 
of  skin  cancers  with  arsenious  acid,  used  in  the  form  of  a 
paste,  usually  known  as  Marsden's  paste,  Prof.  John  A. 
Wveth,  M.  D..  said  in  a  lecture  delivered  at  the  New  York 


CANCKR.  147 

Polyclinic,  "If  I  had  a  superficial  epithelioma  develop  any- 
where on  my  body  where  I  could  use  Marsden's  paste,  I 
would  prefer  that  method  of  treatment  to  the  knife.  If  the 
disease  had  existed  so  long  that  the  paste  alone  could  not 
be  relied  upon,  I  would  prefer  to  have  the  malignant  pro- 
cess first  cut  or  scraped  away,  and  then  have  the  paste  ap- 
plied. In  this  way  we  get  more  satisfactory  results  than  by 
any  other  treatment  I  know  of." 

The  formula  of  Marsden's  paste  is  sometimes  seen  in 
slightly  different  proportions,  but  when  seen  in  the  weaker 
forms  the  formula  is  usually  intended  to  be  applied  to  the 
tender  surfaces,  as  the  lip,  anus,  glans  penis,  etc.  Some- 
times morphine  is  added,  sometimes  cocaine.  The  follow- 
ing formula  is  the  one  preferred  by  Prof.  Wyeth  and  given 
by  many  others : 

ty     Acid  Arsenious 5  ij. 

Powd.    Acacia 5  j. 

Cocaine  Muriate grs.x  to  xviij 

Mix. 

Add  a  small  quantity  of  water  and  rub  into  a  paste  to 
the  consistency  of  rich  cream.  The  paste  should  always  be 
freshly  prepared  and  spread  on  a  piece  of  rubber  plaster  and 
applied  as  soon  as  the  oozing  of  blood  from  the  curetting 
has  ceased.  It  should  be  allowed  to  remain  from  eighteen  to 
thirty-six  hours,  when  if  required  another  fresh  application 
can  be  made.  When  a  cancerous  growth  has  been  thoroughly 
and  sufficiently  cauterized  by  this  method,  on  removal  of  the 
plaster  the  neoplasm  will  be  found  to  be  black  and  necrosed, 
and  surrounded  by  a  swollen  and  inflamed  area.  A  flax  seed 
poultice  is  then  applied  and  continued  until  the  slough 
separates.  After  the  slough  separates,  if  any  cancerous  tis- 
sue remains  not  necrosed,  or  if  the  hard  nodular  base  or 
margin  remains  unaffected,  another  application  of  the  paste 
is  necessary.  This  may  be  made  weaker,  only  one  drachm 
of  arsenious  acid,  and  eight  or  ten  grains  of  cocaine,  and 
allowed  to  remain  a  shorter  time. 


148  CANCER. 

When  all  cancerous  tissue  has  been  destroyed,  a  simple 
dressing  is  all  that  is  necessary.  It  usually  heals  without 
interruption.  Protonuclein  internally  and  externally  is 
always  beneficial. 

Various  other  formulae  will  here  follow^  with  such  com- 
ments as  have  suggested  themselves.  No  physician  is  ex- 
pected to  give  all  of  them  a  trial,  although  many  of  them 
have  merit  and  are  possibly  better  adapted  to  some  forms 
than  the  favorite  formula  first  mentioned.  For  this  reason 
every  available  formula,  deemed  of  apparently  sufficient 
value,  will  be  found  in  the  following  pages,  and  these  com- 
prise, I  believe,  practically  everything  that  is  known  in  the 
treatment  of  cutaneous  cancer  by  local  applications  of  caus- 
tics and  other  tissue  destroying  agents. 


Fuschius'  Paste. 
1^     Arsenious  Acid. 

Vegetable  Charcoal. 

Powd.   Serpentaria aa  q  j. 

Mix.     Make  into  a  thick  paste  with  water  and  apply. 

Esmarck's  Caustic  Powder. 
I£     Acid  Arsenious. 

Morphine  Sulphate aa  3  j. 

Mercurous    Chloride,    mild 5  j- 

Powd.  Acacia 5  vj. 

Mix.     Make  into  a  paste  as  needed  by  adding  water. 
This  is  said  to  be  practically  painless. 


Guy's  Arcanum. 

A  secret  formula,  much  used  in  former  years. 

I£     Acid  Arsenious. 
Powd.  Sulphur. 

Hog's  Fennel,  (Peucedanum  Off.) 
Ranunculus  Sylvestris aa  ."  j. 

Mix.     Make  into  paste  with  water. 


CANCER.  149 

Februre's  Treatment  for  Cancer. 

I>      Acid  Arsenious gr.  x. 

Distilled  water Oj. 

Mix.     When  dissolved  add 

Fl.  Ext.  Conium fl.  o  J- 

Liq.  Plumb.  Subacetate fl.  5  iij. 

Tr.  Opium fl.  o  j. 

Mix.  Use  as  a  wash  and  apply  locally,  allowing  it  to 
dry,  every  morning. 

Internally  with  the  above. 

I?     Acid  Arsenious gr.  ij. 

Powd.  Rhubarb 3  iv. 

Syr.  Chicory fl.  o  viij . 

Water   q.  s.  ad.  Oj. 

Mix.     Sig.     Teaspoonful  night  and  morning. 

Cerny's  Liquid  Caustic. 

I£     Acid  Arsenious 5  j. 

Alcohol, 

Water   aa  %  vj . 

Mix.  After  a  preliminary  curetting  and  cleansing  of 
the  surface  of  the  cancer,  the  mixture  is  applied  with  a 
brush.  Allow  to  dry  and  apply  no  dressing.  Apply  thus 
daily  gradually  increasing  the  strength  until  the  proportion 
of  arsenic  is  two  drachms  to  the  above  quantity  of  alcohol 
and  water.  The  cancer  will  become  covered  with  a  scab 
which  will  gradually  thicken  and  change  from  yellowish  to 
black,  and  will  gradually  become  detached  by  suppuration 
and  can  easily  be  removed.  After  removal  the  solution  is 
again  applied  in  the  former  strength,  and  the  result  is 
watched.  If  a  thin,  easily  detachable,  yellow  pellicle  only 
is  formed,  the  cancer  is  destroyed  and  the  ulceration  will 
heal  up.  If  a  dark,  firm  and  adherent  crust  appears,  the 
cancerous  tissue  is  not  all  removed  and  the  treatment  must 
be  repeated. 


150  CANCER. 

Treatment  may  occupy  from  one  to  three  months,  which 
is  objectionable.  It  is,  however,  painless,  and  is  on  this 
account  desirable. 


Hebra's  Paste. 
I£     Acid  Arsenious 5  j. 

Mercuric  Sulphide,  red 3  iij. 

Vaseline    o  nJ  • 

Mix. 

Martin's  Powder. 

I£     Acid  Arsenious 5  j . 

Powd.  Cancer  Root,  (Orobanche  Virg) .  .  3  j. 
Mix.    Apply  dry  to  ulcerations. 


Frere  Come's  Paste. 
I£     Acid  Arsenious gr.  x. 

Mercuric  Sulphide,  red gr.  xl. 

Animal   Charcoal gr.  x. 

Mix.     Make  into  paste  with  water  as  needed  for  use. 

The  Zinc  Salts. 

As  has  been  previously  mentioned,  Chloride  of  Zinc  is 
one  of  the  best  remedies  at  our  command,  and  has  many 
strong  adherents  who  claim  very  excellent  results. 

In  mixing  preparations  containing  chloride  of  zinc  the 
mixture  should  be  stirred  with  a  horn  spatula,  as  iron  will 
be  quickly  corroded.  Probably  an  aluminum  spatula  would 
also  answer.  The  zinc  salts  form  a  whitish  or  grayish  eschar 
which  can  be  removed  in  from  seven  to  fourteen  days,  and 
when  it  begins  to  loosen  it  is  advisable  to  apply  an  elm  bark 
or  flaxseed  poultice  to  facilitate  its  removal.  These  salts 
cause  considerable  pain,  but  it  can  be  largely  controlled  by 
morphia  or  other  anodynes.  The  most  popular  salt  of  zinc 
is  the  chloride,  although  the  nitrate  and  sulphate  are  some- 
times used. 


CANCER.  J5J 

The  following  formula  is  perhaps  the  most  popular  for 
the  application  of  the  chloride: 

I£     Powd.  Sanguinaria i  part. 

Powd.  Galangal 3  Parts 

Zinc  Chloride q.  s. 

Mix  the  two  powders  and  gradually  add  sufficient 
chloride  of  zinc  to  make  a  thick  paste  consistent  enough  to 
be  formed  with  the  fingers.  Form  a  piece  of  this  paste  into 
a  shape  that  will  cover  the  cancer  and  about  one-fourth  of 
an  inch  on  each  side  of  it,  and  one-eighth  of  an  inch  in 
thickness. 

Apply  this  to  the  cancer  and  retain  in  place  with  strips 
of  adhesive  plaster  and  apply  a  soft  compress  and  bandage. 
Let  it  remain  in  place  for  twenty-four  hours  and  apply  a 
fresh  plaster.  Repeat  this  process  for  three  or  more  days, 
until  the  tumor  becomes  shriveled  and  devitalized.  Dress 
with  basilicon  ointment  daily  and  allow  the  slough  to  be- 
come detached  without  using  any  traction.  This  will  take 
place  in  a  week,  approximately. 

Continue  dressing  with  basilicon  ointment  until  healed. 
The  Galangal  and  Sanguinaria  with  Chloride  of  Zinc  form  a 
paste  without  the  addition  of  water.  It  should  be  made 
fresh  each  morning.  The  small  variety  of  Galangal  Root, 
Maranta  Galanga,  is  the  root  preferred. 


Dr.  Bright' s  Formula. 
Dr.  Bright,  of  Lexington,  Ky.,  published  the  following 
formula  as  his  most  successful  treatment  for  cancer,  and  is 
highly  recommended  by  other  physicians  who  have  used  it 
for  more  than  twenty-five  years : 

I£     Solid  Ext.  Podophyllum 3  j. 

Zinc   Chloride 3  iij- 

Starch  3  ss. 

Red  Saunders 3  ss. 

Water,  q.  s.  to  make  a  thick  paste. 


152  CANCER. 

Spread  on  cotton  cloth  one-fourth  of  an  inch  in  thick- 
ness, sufficiently  large  to  cover  the  cancer  and  embracing 
one-fourth  of  an  inch  of  margin.  Bind  in  place  with  adhe- 
sive plaster  and  allow  it  to  remain  twenty-four  hours.  Re- 
move and  apply  freshly  after  washing  the  surface  of  the 
cancer.  Repeat  three  or  four  days  in  succession  or  until 
the  surface  of  the  growth  becomes  hard  and  white.  Poul- 
tice as  previously  detailed  for  six  or  eight  days  and  the 
slough  will  fall  out.  The  poultices  should  be  renewed  every 
six  hours.  If  the  cancerous  tissue  is  not  all  removed,  re- 
apply as  before.  When  all  is  removed  dress  with  an  oint- 
ment composed  of  equal  parts  of  white  wax,  mutton  tallow 
and  lard,  melted  together  and  stirred  until  cold.  Before 
dressing  wash  the  edges  with  warm  water  and  castile  soap 
and  remove  filth  and  hardened  crusts.  A  good  dressing 
other  than  the  above  may  be  made  by  adding  Balsam  Peru, 
one  drachm  to  one  ounce  of  vaseline.  During  treatment 
give  anodynes  as  required,  also  aperients  and  such  consti- 
tutional treatment  as  the  patient  may  require. 


Bougard's  Cancer  Paste. 

I£     Mercuric  Sulphide,  red, 

Ammonium  Chloride aa.  gr.  xl. 

Mercuric  Chloride,  Corros gr.  iv. 

Acid  Arsenious gr.  viij. 

Wheat  Flour. 

Starch. 

Zinc    Chloride aa  §  j. 

Water,  boiling %  iss. 

Mix.  Dissolve  the  chloride  of  zinc  in  the  boiling  water. 
Mix  all  the  other  ingredients  in  a  glass  mortar,  and  pour 
the  solution  of  the  zinc  slowly  into  the  mortar,  stirring 
briskly  until  thoroughly  mixed.  Let  stand  twenty-four 
hours. 


CANCER.  153 

Apply  on  muslin  after  preliminary  curetting  and  let  it 
remain  for  twenty-four  hours.  The  poulticing  and  after 
treatment  are  the  same  as  when  Marsden's  paste  is  used. 

This  is  an  active  preparation,  but  acts  on  healthy  tissue 
as  well  as  on  diseased.  It  is  used  by  several  well  known 
New  York  Dermatologists  with  good  success. 


Felix's  Paste. 

I£     Zinc  Chloride gr.  ex. 

Wheat  Flour gr.  cxij . 

Starch   gr.  xxxvi  j . 

Mercuric  Chloride,  Corr.  .  .  .'. gr.  j. 

Iodol. 

Croton  Chloral. 

Acid  Carbolic  Cryst. 

Camphor aa  gr.  x. 

Mix.     Make  into  a  paste  with  water.     Apply  and  let 
it  remain  six  to  twenty-four  hours. 


Sherman's  Paste. 
I£     Zinc  Chloride. 

Alum  aa  gr.  v 

Acid  Tannic gr.  ij 

Persulphate  of  Iron gr 

Glycerine q.  s.  to  make  paste. 


nj. 


The  following  formula  is  used  by  several  Western  can- 
cer specialists : 

I?     Zinc  Chloride. 
Podophyllum. 

Powd.  Opium aa  5  ij. 

Mix.  Make  paste  and  apply  to  cancer,  spread  on  a 
muslin  cloth.  It  is  something  similar  to  the  Bright  for- 
mula before  given,  and  general  directions  given  there  will 
here  apply. 


154  CANCER. 

Hundreds  of  other  formulae  containing  Arsenious  Acid, 
Chloride  of  Zinc,  Sulphate  of  Zinc  and  Nitrate  of  Zinc,  as 
also  those  containing  alkaline  remedies  could  be  furnished, 
but  it  would  be  a  useless  repetition  and  could  serve  no  other 
purpose  than  to  confuse  the  practitioner  and  occupy 
valuable  space.  A  few  other  formulae  are  however  given 
hereafter  which  are  advocated  and  used  by  their  adherents. 
As  an  addition  to  our  fund  of  general  knowledge  on  the 
subject  they  are  valuable,  even  if  they  served  no  other 
purpose.  The  majority  of  secret  remedies  are  often  nothing 
more  than  old  combinations  under  a  different  disguise  and 
these  formulae  may  assist  in  their  recognition. 


Davisson's  Cancer  Remedy. 
ty     Sodium  and  Potassium  Tartrate. 

Sulphur. 

Zinc  Sulphate. 

Arsenious  Acid aa  §  j. 

Mix  well  and  add  the  yolks  of  eight  eggs  and  beat  into 
a  batter.  Bake  in  an  oven  until  dry  and  hard.  Powder  the 
mixture  and  when  ready  for  use  make  a  paste  with  sufficient 
for  one  application  by  the  addition  of  the  yolk  of  an  egg. 
Spread  on  sore  and  cover  with  muslin  or  cheese  cloth  and 
apply  a  coating  of  yolk  of  egg  alone.  Bind  in  place  with 
bandage  and  allow  it  to  remain  until  swelling  and  inflamma- 
tion appears  and  disappears.  Remove  and  poultice.  Cu- 
rette, scarify  or  blister  the  skin  if  the  cancer  is  not  ulcer- 
ating, before  applying. 


Lassar's  Paste. 

I£     Acid   Salicylic gr.  x. 

Powd.  Starch 3  ij. 

Zinc    Oxide 3  ij. 

Lard    3  iv. 

Mix. 

This  preparation  was  originated  by  Lassar  who  used  it 


CANCER.  155 

in  connection  with  Arsenic  internally.  It  is  designed  for 
slow  work,  gradual  destruction  of  tissue,  and  is  not  as  satis- 
factory as  other  previously  given  formulae.  It  is  also  recom- 
mended for  eczema,  dermatitis,  warts,  etc. 

Salicylic  Acid  may  be  used   in   considerably   stronger 
proportions,  as  for  instance : 
R     Acid  Salicylic. 

White   wax aa  3  j . 

Parafine. 

Oil  of  Sweet  Almonds aa  3  ij. 

Mix.    Melt  with  gentle  heat  and  stir  until  cold. 


VEGETABLE  REMEDIES. 

Certain  remedies  of  vegetable  origin  enjoy  somewhat  of 
a  reputation  in  the  treatment  of  cancer  of  the  skin.     Some 
have  already  been  referred  to  while  others  will  follow. 
Dr.  Lombard's  Remedies. 

Doctor  Lombard,  now  dead,  was  formerly  located  in 
Maine,  where  he  had  the  reputation  of  being  a  successful 
"cancer  doctor."  The  remedies  he  employed  were  given  to 
the  profession  after  his  death  by  a  physician  who  attended 
him  during  his  last  illness  and  to  whom  they  were  confided, 
whether  with  the  understanding  that  they  were  to  be  kept 
secret  or  not,  is  unknown  to  me. 

When  the  cancer  was  small  he  used  the  inspissated  juice 
of 

Phytolacca  Decandra, 
which  was  applied  in  the  form  of  a  plaster  and  repeated  until 
sloughing  took  place.     The  after  treatment  was  a  dressing 
with  simple  cerate. 

If  the  cancer  was  large  he  used  a  paste  composed  of 

Zinc  Chloride  and  Powd.  Sanguinaria, 

until  an  eschar  was  produced,  when  the  Phytolacca  plaster 

was    applied   as    in   the    smaller   varieties    until    the   mass 

sloughed  away. 


156  CANCER. 

Phytolacca  Root  has  also  been  employed,  in  the  fol- 
lowing combination : 

^     Solid  Ext.  Phytolacca. 

Solid  Ext.  Podophyllum. 

Solid  Ext.  Sanguinaria. 

Acid  Chromic. 

Carbon  Tetra  Chloride,  aa  equal  parts. 
Mix.    Apply  in  the  form  of  a  paste. 


Cheudonium  Majus. 

This  drug  was  first  exploited  by  Denissenko,  who  claims 
to  have  obtained  good  results  from  its  use.  His  method  of 
using  it  is  to  give  internally  thirty  to  seventy-five  grains  of 
the  extract,  dissolved  in  water,  every  day  throughout  the 
treatment,  and  to  inject  into  the  substance  of  the  tumor,  at 
different  points,  as  close  to  the  margin  of  the  growth  as 
possible,  from  two  to  four  minims  of  a  mixture  of  equal 
parts  of  the  extract,  glycerine  and  water,  not  to  exceed  a 
syringeful  in  all.  The  frequency  with  which  these  injections 
are  given  is  not  stated  in  the  literature  at  my  disposal.  The 
surface  of  the  tumor  is  also  painted  with  this  mixture. 

The  effects  of  the  treatment  noted  were :  1 .  The  sal- 
low hue  of  the  skin  disappeared.  2.  Softening  of  the  tu- 
mor set  in.  3.  After  from  three  to  five  days,  there  formed 
at  the  points  of  injection,  fistulous  tracts  about  which  the 
softening  process  progressed  with  special  rapidity.  4.  In 
from  fifteen  to  twenty  days  a  line  of  demarcation  could  be 
distinguished  between  the  morbid  and  the  healthy  tissue. 
5.  The  tumor  diminished  in  size  and  gradually  grew  less. 
Sufficient  time  has  not  elapsed  to  give  further  reports  of  this 
treatment. 


Alveloz  Milk. 
A    juice    derived    from    a    Brazilian    plant    known    as 
Euphorbia  Heterodoxia,  possesses  the  power  of  dissolving 
fibrin  and  is  somewhat  caustic.     In  the  treatment  of  cancer 


CANCER.  157 

it  is  applied  with  a  camel's  hair  brush  and  in  twenty-four 
hours  a  strong  decoction  of  tobacco  is  applied.  In  twenty- 
four  hours  the  Alveloz  is  repeated  and  again  the  tobacco  in 
the  same  order  until  the  diseased  tissue  sloughs  out.  It  is 
not  used  much  in  this  country,  neither  is  its  value  entirely 
established. 


The  internal  use  of  Butternut,  in  the  form  of  an  extract 
of  the  bark,  constituted  the  treatment  of  one  Samuel 
Thompson,  the  author  of  a  work  on  botanic  remedies.  He 
advised  the  use  of  ten  grains  of  the  solid  extract  every  four 
hours. 


FOR  INTERNAL  CANCER,  with  or  without  Local 
Manifestations. 

A  treatment  for  internal  cancer,  existing  either  in  con- 
junction with  or  independently  of  external  growths  or  ul- 
cerations, was  given  me  by  a  well  known  physician  who  has 
had  experience  with  it,  and  who  uses,  it  in  all  scrofulous  or 
tuberculous  conditions  as  well  as  in  malignant  neoplastic 
growths.    He  considers  it  one  of  his  best  remedies. 

^     Fl.  Ext.  Rumex  Crispus fl.  5  j. 

Fl.  Ext.  Phytolacca  Decandra fl    3  j. 

Syrup. 

Water aa  fl.  §  ivss. 

Mix.     Sig.     One  ounce  three  times  daily. 
In  local  manifestations,  or  in  purely  local  epithelioma, 
ulcers  or  indolent  sores  he  uses  the  following  ointment : 

ty     Fl.  Ext.  Phytolacca  Decan fl.  3  j. 

Fl.  Ext.  Rumex  Crispus fl.  §  ij. 

Yellow   Wax o  j- 

Benzoinated  Lard 5  iij. 

Melt  the  last  two  ingredients  and  remove  from  fire. 
Add  the  fluid  extracts  to  the  hot  mixture  and  stir  until  cold. 

Apply  several  times  daily. 


158  CANCER. 

PROTONUCLEIN. 

Among  the  newer  remedies  for  the  treatment  of  can- 
cerous growths,  the  biological  remedy  Protonuclein  merits 
a  prominent  position.  In  the  second  edition  of  this  work 
this  remedy  was  mentioned  and  its  use  advocated,  especially 
as  an  after  dressing  in  cases  that  appeared  difficult  to  heal. 
Its  physiological  action  however,  when  taken  internally, 
seems  now  to  be  quite  as  important  and  the  many  reports  of 
physicians  that  have  since  appeared  in  medical  periodicals 
substantiate  every  claim  then  made  for  it. 

Nucleins  of  vegetable  origin  are  in  the  market,  but  these 
differ  materially  from  the  animal  product,  both  in  form  and 
action.  My  experience  with  the  former  has,  however,  been 
somewhat  limited,  having  always  used  the  Protonuclein 
made  by  Reed  &  Carnrick. 

Its  local  action  in  the  treatment  of  Epithelioma  and  other 
malignant  growths  is  similar  to  that  in  the  treatment  of  rectal 
ulcers,  fistulae,  etc.,  yet  in  addition  we  here  obtain  its  anti- 
toxic action,  by  which  the  germs  and  germ  products  are 
promptly  destroyed  and  what  is  probably  more  important, 
this  result  is  not  alone  obtained  from  the  remedy  directly,  but 
by  the  stimulation  given  the  cellular  structures  themselves, 
which  effect  remains  even  after  the  activity  of  the  remedy 
has  been  expended. 

One  of  its  most  important  indications  is  the  use  of  the 
Special  Protonuclein  powder  as  a  dressing  after  the  cancer- 
ous growth  has  sloughed  away  from  the  action  of  local  ap- 
plications of  caustics  and  cauterants. 

These  openings  have  very  frequently  been  quite  difficult 
to  heal,  yet  with  this  remedy  at  our  command  we  can  ap- 
proach one  of  the  most  formidable  conditions  without  the 
usual  apprehension. 

In  tumors  where  the  skin  is  as  yet  unbroken  this  remedy 
may  be  used  hypodermatically,  being  injected  into  the  base 
of  the  growths,  as  close  to  the  dividing  line  between  the 
affected  and  unaffected  part  as  possible.     Ten  grains  of  the 


CANCER.  159 

Special  powder  are  mixed  with  one  drachm  of  pure  water 
at  a  temperature  of  98  to  100  degrees.  Allow  the  mixture 
to  stand  for  twenty  minutes,  thoroughly  shaking  it  at  inter- 
vals. Finally  permit  the  insoluble  particles  to  settle  and 
draw  off  ten  minims  of  the  supernatant  fluid  and  inject.  Pre- 
pare freshly  for  each  day's  use.  This  is  to  be  repeated  twice 
a  day.  The  same  treatment  can  also  be  applied  in  open  sores 
of  a  malignant  nature,  in  addition  to  the  internal  administra- 
tion. 

Internally,  in  all  cases  the  regular  Protonuclein  is  to  be 
given  in  such  doses  as  seem  warranted.  Three  to  ten  grains, 
three  times  a  day,  may  be  given,  according  to  effect  desired 
and  its  action  on  the  patient.  Continued  increase  of  pulse 
indicates  longer  intervals  between  doses.  Continued  in- 
crease of  temperature  indicates  smaller  doses  at  shorter 
intervals.  General  urticaria  indicates  smaller  doses  at  longer 
intervals.  This  latter  condition  indicates  an  excess  of  cellu- 
lar activity  and  is  a  positive  order  for  smaller  doses. 

It  is  best  administered  two  hours  before  meals,  or  when 
the  stomach  is  empty. 

Locally,  use  the  Protonuclein  Special  as  one  would  an 
ordinary  dusting  powder.  Always  cleanse  the  parts  before 
applications  with  Hydrozone  until  all  pus  formations  are 
cleared  away.  As  many  of  the  other  antiseptics  destroy  or 
modify  the  action  of  the  Protonuclein,  no  other  solutions 
should  be  used,  unless  washed  off  after  their  action  has  been 
secured.  If  slight  pain  should  follow  the  application  of  the 
powder,  no  anxiety  need  be  felt  as  it  will  disappear  in  ten  to 
twenty  minutes. 

As  a  dressing  after  the  caustic  treatment  it  is  without  an 
equal  and  should  always  be  used,  whether  the  wound  exhibits 
any  inclination  to  be  difficult  to  heal  or  not. 


l6o  CANCER. 

SODIUM  ETHYLATE  TREATMENT. 

Given  a  case  of  cancer,  first  cleanse  the  ulcer  with  pure 
Hydrozone.  Place  the  patient  in  a  position  so  that  it  will 
remain  in  contact  with  the  ulcer  until  ebulition  has  ceased. 

Dry  the  parts  with  absorbent  cotton  and  pour  over  or 
into  the  ulcer  cavity  a  ten  per  cent,  solution  of  cocaine  and 
allow  it  ten  minutes  time  for  action.  Dry  again  and  apply 
to  the  surface  full  strength  Ethylate  of  Sodium,  which  can 
be  obtained  by  allowing  the  crystals  to  deliquesce.  This 
agent  is  a  strong  and  painful  caustic,  and  the  application  of 
cocaine  does  not  always  entirely  prevent  pain.  When  it 
touches  the  ulcer  a  peculiar  change  is  observed.  If  the 
wound  is  clean  the  fluid  spreads  itself  out  rapidly,  and  where 
there  is  diseased  tissue  the  part  turns  instantly  black.  The 
rest  of  the  surface  becomes  brown.  If  the  ulcer  is  not  clean 
the  entire  surface  turns  black.  An  application  is  made  over 
the  whole  surface.  Over  the  black  parts  the  ethylate  soon 
becomes  gummy  and  must  not  be  disturbed.  The  entire 
surface  is  now  covered  with  the  following  powder : 

J^     Acetanilide    3  j. 

Aristol 3  ij . 

Acid  Boric §  j. 

Mix. 

Considerable  oedema  follows  the  first  application  but 
soon  disappears.  Pain  also  entirely  ceases  as  soon  as  the 
caustic  action  is  completed. 

Spread  a  piece  of  wadding  with  vaseline  and  cover  the 
ulcer,  apply  cotton  and  bandage.  Dress  the  sore  every  day, 
wash  ulcer  clean  and  re-touch  such  spots  with  the  ethylate 
as  show  signs  of  diseased  tissue.  Use  a  glass  rod  in  making 
the  applications.  Cures  are  effected  in  from  two  to  five 
weeks.  Throughout  the  treatment,  give  the  patient  one  or 
two  three  grain  tablets  of  protonuclein,  three  times  a  day, 
two  hours  before  meals.     This  remedy  is  important  in  this 


CANCER.  1 6] 

connection  as   it  increases  the  white  blood  corpuscles  and 
assists  in  removing  the  oedema. 


Dr.  Gunn's  Cancer  Remedy. 

The  following  formula  appears  in  Dr.  Gunn's  "Family 
Physician,"  and  I  have  seen  it  endorsed  recently  by  several 
physicians  practicing  in  Kentucky,  who  used  it  with  success : 
ty     Red  Oak  Bark. 

White  Oak  Bark. 

Phytolacca  Root. 

Persimmon  Bark. 

Viburnum  Prun.  Bark. 

Sheep  Sorrel. 

Red  Clover  Blossoms aa.  ^  ij. 

Blackberry  Root §  iv. 

Cinnamon    Bark §  j. 

Boil  the  above  in  five  gallons  of  water  until  reduced 
to  one  gallon.     Strain  and  add 

Alum. 

Sodium  Biborate aa  f,  iv. 

Sig.  Wash  the  cancer  with  this  three  or  four  times  a 
day  until  the  cancer  is  devitalized.  Dress  with  a  salve  made 
of 

Mutton  Suet. 

Yellow  Wax. 

Crude  Turpentine. 

Sweet  Gum aa  equal  parts. 

Mix  by  melting  all  together  over  a  slow  fire.  When  all 
have  melted,  remove  from  fire  and  stir  until  cold. 

Sig.    Apply  on  muslin  and  keep  in  place  by  bandage. 


162  DRUG    ADDICTION. 


DRUG   ADDICTION 


Notwithstanding  the  oft  repeated  assertion,  even  by 
such  as  claim  to  have  had  opportunity  for  systematic  obser- 
vation, that  the  extent  of  drug  addiction  in  our  country  is 
constantly  being  over-estimated,  and  that  the  danger  to  be 
feared  from  an  increase  of  the  same  is  more  imaginary  than 
real,  the  fact  remains  that  drug  addiction,  especially  that  of 
opium  or  its  alkaloids,  and  cocaine,  is  to-day  a  cruel,  merci- 
less monster  whose  almost  relentless  grasp  holds  in  a  thral- 
dom infinitely  worse  than  slavery,  its  legion  of  victims  in  all 
parts  of  the  world. 

The  far-reaching  effect  of  drug  addiction  cannot  be 
imagined,  much  less  accurately  determined,  and  only  such  as 
have  had  the  opportunity  of  observing  a  bright,  intellectual 
and  promising  young  man  gradually  lose  his  ambition,  his 
character,  his  manhood,  his  all,  and  sink  into  an  oblivion 
worse  than  death,  can  understand  the  full  import  of  the 
assertion  that  drug  addiction  constitutes  a  most  effective 
barrier  to  the  elevation  of  some  of  our  brightest  minds,  and 
too  frequently  clouds  the  most  brilliant  intellects. 

Morphine  daily  incapacitates  the  noble,  busy  physician, 
defiles  the  sacred  desk,  sullies  the  ermine  of  the  bench,  ruth- 
lessly enters  every  profession  and  fastens  its  terrible  and 
merciless  fangs  upon  every  class  of  people. 

No  station  in  life  is  exempt  from  the  baneful  influences 
of  this  steadily  growing  evil ;  all  classes  contribute  their  quota 
to  the  insatiable  army,  who,  as  without  a  leader,  invariably 
meet  the  same  fate,  unless  rescued  by  such  of  the  medical 
profession  who  have  given  the  subject  sufficient  attention  to 


DRUG    ADDICTION.  163 

recognize  the  truly  charitable  service  that  can  be  rendered 
in  such  cases,  and  who  not  necessarily  consider  the  substan- 
tial financial  returns  accruing  therefrom. 

The  treatment  of  drug  addiction  is  so  little  understood 
by  physicians  in  general,  that  it  is  almost  universally  regarded 
as  an  incurable  disease,  and  by  their  inattention  to  it  they 
practically  confess  themselves  inadequate  to  the  task  of 
curing  it. 

The  successful  treatment  of  drug  addictions  demands 
three  requisites  as  follows  : 

1.  The  confidence  of  the  patient.  Everyone  knows  the 
intense  degree  of  secretiveness  that  develops  in  an  opium  or 
morphine  habitue.  The  fear  of  an  interruption  in  his  supply 
is  sufficient  to  rouse  an  almost  superhuman  energy  to  fore- 
stall it,  and  indeed  the  most  careful  vigilance  on  the  part  of 
the  shrewdest  physician  is  often  entirely  inadequate  to  cope 
with  the  schemes  of  the  most  ignorant  victim  of  drug  addic- 
tion. Many  habitues  will  object  to  treatment  for  the  reason 
that  they  have  all  experienced  the  pangs  of  withdrawal,  and 
have  an  idea  that  if  treatment  would  be  taken,  they  will  be 
obliged  to  pass  through  extreme  torture  before  they  can 
obtain  freedom,  and  consequently  postpone  the  attempt  from 
one  season  to  another.  There  are  but  few  institutions  now 
in  business  who  practice  the  sudden  withdrawal  system  unless 
it  is  done  under  the  influence  of  certain  other  narcotics,  which 
system  is  perfectly  rational  and  proper,  but  applicable  only 
to  those  who  are  strong  and  vigorous.  Some  institutions 
claim  from  ninety  to  ninety-five  per  cent,  of  cures  by  this 
method,  known  as  the  "Quick  Cure"  system,  but  in  order  to 
obtain  these  results,  the  cases  must  be  carefully  selected. 
Confidence  therefore  is  the  first  prime  requisite  to  be  sought 
for;  without  it  everything  will  fail.  The  physician  must 
assure  his  patient  that  in  case  he  is  not  fully  supported  by  the 
treatment,  that  if  a  craving  for  the  drug  comes  on,  he  will  see 
to  it  that  he  is  supplied  with  enough  to  meet  his  needs,  and 
in  no  instance  must  this  promise  be  broken.     If  the  patient 


164  DRUG    ADDICTION. 

is  once  disappointed,  rest  assured  he  will  institute  measures 
to  prevent  any  such  calamity  in  the  future. 

The  next  requisite  is,  the  patient  must  be  willing  to  be 
cured.  Paradoxical  as  it  may  seem,  one  is  frequently  con- 
sulted by  opium  or  morphine  addicts  for  relief  from  the  crav- 
ing, while  at  the  same  time  they  are  daily  consuming  more 
of  the  drug  than  they  actually  need  to  be  free  from  annoy- 
ance, and  who  after  treatment,  after  the  craving  has  been 
removed,  express  and  often  gratify  a  desire  for  a  single  dose, 
merely  to  note  the  results.  The  results  are  too  well  known 
to  require  mention,  and  too  strong  injunction  against  such 
procedure  cannot  be  given.  The  collaboration  of  the  patient 
with  the  physician  is  absolutely  essential. 

The  third  requisite.  The  physician  who  essays  the 
successful  treatment  of  drug  addictions  must  possess  the 
means  to  cure,  and  exercise  good  judgment  in  employing 
them.  An  adequate  and  reliable  knowledge  of  the  various 
phases  presented  by  a  number  of  these  cases,  and  the  special 
means  to  be  employed  in  effecting  successful  terminations 
can  only  partially  be  obtained  by  reading  and  study ;  actual 
experience  is  necessary.  It  is  by  experience  only  that  the 
physician  will  be  able  to  accurately  determine  the  patient's 
needs,  whether  he  really  requires  the  drug  or  whether  he 
only  thinks  so ;  to  accurately  determine  the  amount  of  actual 
suffering  some  may  endure  without  complaint,  and  also  to 
make  a  liberal  allowance  for  the  profuse  and  exaggerated 
pleadings  of  those  whose  most  trifling  discomfort  renders 
them  unconsolable.  In  these  later  named  cases,  the  judi- 
cious use  of  a  hypodermatic  injection  of  distilled  water  will 
often  clear  up  a  diagnosis. 

TREATMENT. 

In  the  treatment  of  drug  addictions  several  points  must 
be  considered  as  bearing  directly  on  the  object  for  which  the 
remedies  are  employed.  The  first  is,  to  relieve  the  patient  of 
the  craving  he  possesses  for  the  drug,  and  to  enable  him  to 
discontinue  its  use. 


DRUG    ADDICTION.  1 6.5 

The  second  is,  to  combat  the  physical  and  mental  dis- 
turbances that  take  place  during  the  period  of  withdrawal, 
and  to  render  this  process  as  free  from  pain  and  discomfort 
as  possible.  The  third  is,  to  prevent  the  patient  from  return- 
ing to  the  use  of  the  drug,  a  relapse.  In  the  selection  of 
cases,  good  judgment  again  is  necessary.  Let  no  one  for  a 
moment  imagine  that  the  treatment  of  drug  addictionists 
can  be  compared  with  a  political  job  to  which  no  work  and  a 
fat  salary  is  attached,  nor  that  all  cases  are  curable,  for  to 
one  who  thus  allows  his  mind  to  wander,  the  disappointment 
will  be  keen.  A  certain  number  of  cases  are  in  reality  easy 
to  cure,  others  are  more  or  less  difficult  and  still  others  are 
incurable. 

Among  the  latter  class,  we  note  those  who  are  very 
feeble  and  usually  of  an  advanced  age,  say  from  70  years 
upward.  The  pathological  changes  that  have  taken  place  in 
these  subjects,  are  beyond  repair ;  the  digestive  and  elimina- 
tive  processes,  have  practically  been  abolished;  the  gastric 
secretions  have  been  almost  entirely  checked;  peristaltic 
movements  are  very  much  decreased;  the  sensibility  of  the 
alimentary  mucous  membranes  is  so  benumbed  that  there  is 
anorexia,  simply  because  the  patient  does  not  know  he  is 
hungry.  These  cases  live  on  their  reserve  of  former  years, 
to  which  the  waste  of  flesh  and  loose  skin  is  ample  testi- 
mony. The  mind  of  these  cases  becomes  narrow,  and  the 
range  of  reason  is  diminished  to  but  a  small  portion  of  its 
former  latitude.  In  these  cases,  which  are  so  well  marked 
that  they  cannot  fail  to  be  recognized,  treatment  is  useless. 
Xo  system  of  medication  can  restore  the  practically  dead 
cells  any  more  than  the  dead  body,  a  combination  of  cells, 
can  be  brought  to  life.  The  only  hope  that  can  be  extended 
to  such,  is  that  of  being  made  as  comfortable  as  possible,  un- 
til death  ends  the  scene. 

In  passing  judgment  on  cases  which  might  be  supposed 
to  belong  to  this  class,  one  must  be  guarded,  unless  guided 
by  reliable  judgment,  ripened  by  experience,  and  if  a  pos- 
sible chance  of  recovery  may  be  hoped  for,  a  treatment  here- 


1 66  DRUG   ADDICTION. 

after  referred  to,  should  be  begun  as  an  experiment,  and  the 
subsequent  course  determined  from  results  obtained. 

Another  class  of  incurables  is  that  in  which  a  malignant 
and  painful  disease  co-exists  with  the  addiction,  and  which 
in  truth  caused  its  formation.  It  will  be  entirely  useless  for 
any  one  to  speculate  on  the  curability  of  these  cases,  as  the 
analgesic  action  of  opium  is  the  only  comfort  possible  for 
them  to  obtain.  If  the  drug  is  removed,  the  pain  returns  and 
the  patient  is  at  once  in  agony,  and  becomes  uncontrollable 
in  a  short  time.  No  method  of  treatment  can  cure  these 
cases,  no  matter  what  claims  may  be  made  for  it;  the  drug  is 
not  taken  for  its  delightful  sensations,  nor  from  the  craving 
born  of  a  habitual  use  of  it,  but  as  a  panacea  for  pain,  than 
which  there  is  no  better  remedy,  and  the  only  link  between 
the  mortal  and  the  immortal. 

Among  this  class  may  be  mentioned  those  afflicted  with 
epitheliomatous  growths,  chronic  sores  or  ulcers,  renal  or 
hepatic  calculi,  stone,  or  any  disease  or  condition,  which 
while  it  exists,  renders  the  person  thus  afflicted  subject  to 
considerable  pain.  Before  attempting  to  cure  the  addiction, 
the  existing  cause  must  be  removed.  Nothing  other  than 
this  can  be  of  the  least  avail,  nor  merit  the  suspicion  of  hope. 
In  contra-distinction  to  the  above  must  be  noted  the  imagi- 
nary pains  which  the  majority  of  addicts  will  refer  to  the 
stomach,  or  other  internal  organ,  as  an  excuse  for  taking 
their  accustomed  drug.  Where  no  other  symptoms  can  be 
located,  nor  an  intelligent  diagnosis  made  of  some  disease  of 
which  a  symptom  would  be  the  pain  referred  to,  the  state- 
ments must  be  taken  at  their  real  value,  disregarded  entirely, 
and  treatment  at  once  instituted  for  the  removal  of  the  crav- 
ing. This  done,  the  pain  will  be  seen  to  have  mysteriously 
vanished. 

Curable  cases  may  also  be  divided  into  several  classes, 
according  to  length  of  time  the  habit  has  been  present,  path- 
ological changes  and  vitality  of  the  addict.  First,  we  notice 
the  young,  vigorous,  recent  addict  in  whom  the  structural 
changes  are  practically  unnoticeable  and  a  cure  easily  and 


DRUG    ADDICTION.  l6y 

quickly  effected.  Second,  the  addict  of  two  or  more  years 
standing,  in  whom  the  pathological  changes  are  becoming 
apparent,  but  confined  as  yet  to  slight  derangements  of  the 
digestive  system.  Third,  the  addict  of  many  years  standing, 
in  whom  pathological  changes  may  be  found  representing 
all  stages  of  retrograde  metamorphosis.  The  possibility  of 
their  cure  depends  entirely  on  the  degree  of  tissue  degenera- 
tion that  exists,  and  the  manner  in  which  they  respond  to 
the  vitalizing  and  reconstructive  treatment  given  them. 

MODES  OF  WITHDRAWAL. 

While  explicit  and  detailed  directions  are  given  in  the 
instructions  accompanying  the  following  methods  of  treat- 
ment, for  the  withdrawal  of  the  drug,  it  will  not  be  amiss  to 
review  in  a  general  way,  the  various  modes  of  withdrawal 
which  have  in  the  past  been  practiced  and  variously  com- 
mented upon,  and  the  phenomena  that  attend  them. 

Three  modes  of  withdrawal  of  the  drug  can  be  employed, 
i.  The  Gradual  Reduction  Method.  2.  The  Sudden  or 
Abrupt  Withdrawal.     3.    The  Rapid  Reduction  Method. 

THE  MODE  OF  GRADUAL  REDUCTION. 

This  method  implies  the  gradual  decrease  of  the  drug 
in  such  quantities  as  the  condition  of  the  patient  will  allow, 
manifested  by  either  the  absence  or  presence  of  what  Dr. 
Albrecht  Erlenmeyer,  in  his  work  on  the  Morphine  Disease, 
has  termed  "the  phenomena  of  abstinence."  The  more  pro- 
nounced these  phenomena,  the  slower  must  be  the  reduction 
of  the  opiate. 

This  method  of  reduction  is  not  looked  upon  with  favor 
by  a  number  of  well  known  writers  on  the  subject.  The 
objections  expressed  to  it  are  principally,  the  difficulty  of  con- 
trolling the  patient  so  as  to  prevent  him  from  obtaining 
morphine  secretly,  thus  necessarily  preventing  a  cure ;  the 
next  is,  the  claim  that  the  patient  can  better  endure  stronger 
and  more  severe  withdrawal  symptoms  for  a  short  time,  than 
lesser  and  more  prolonged  disturbances ;  and  the  third  is, 


1 68  DRUG   ADDICTION. 

the  longer  period  during  which  the  patient  must  remain 
under  treatment.  These  objections  will  be  touched  upon 
seriatim. 

Control  of  the  Supply  : — As  has  before  been  men- 
tioned the  full  and  complete  confidence  of  the  patient  must  ab- 
solutely be  reposed  in  the  physician,  and  the  patient  must  be 
firm  in  his  determination  to  be  cured,  and  must  co-operate 
with  him.  If  either  of  these  two  essentials  are  wanting,  it 
is  useless  to  attempt  to  effect  a  cure  by  using  this  method  of 
withdrawal,  and  other  and  more  forcible  means  must  be 
employed. 

When  the  patient  trusts  the  physician  implicitly,  knowing 
that  he  will  receive  from  him  sufficient  of  the  drug  to  sustain 
him,  there  is  no  reason  whatever  for  declining  to  use  this 
method. 

Endurance  op  SupPering: — Erlenmeyer  claims  that 
the  sum  total  of  suffering  experienced  by  the  gradual  with- 
drawal, will  be  greater  than  by  the  sudden  or  rapid  method. 
Whether  this  be  true  or  not,  depends  entirely  on  the  medi- 
cinal treatment  administered  at  the  time.  From  his  remarks 
in  this  connection,  it  would  seem  that  we  are  to-day  perhaps 
in  possession  of  knowledge  regarding  the  use  of  certain 
drugs,  to  prevent  serious  withdrawal  symptoms,  with  which 
this  German  authority  was  not  acquainted  fifteen  years  ago, 
and  which  we  employ  with  good  advantage.  It  is  at  any 
rate,  a  fact  quite  positively  established  that  by  the  use  of 
remedies  selected  for  the  purpose,  we  are  enabled  to  tide  a 
selected  class  of  patients  successfully,  and  practically  pain- 
lessly, over  the  period  of  withdrawal,  without  much  difficulty. 

Long  Duration  op  Treatment: — This  is  an  objection 
that  will  have  but  little  weight  with  many  patients.  If  the 
patient  is  such  that  he  is  willing  to  take  plenty  of  time  in 
effecting  a  cure  in  this  manner,  it  would  seem  to  be  of  little 
concern  to  his  physician,  providing  of  course,  the  patient  is 
willing  to  meet  the  necessarily  increased  professional  fee. 
The  majority  of  patients,  who  are  eligible  for  treatment  by 
this  method,  are  of  the  intelligent,  professional  class,  and 


DRUG  ADDICTION.  169 

have  the  ability  of  comparing  the  advantages  of  one  method 
of  treatment  with  another,  selecting  the  one  best  suited  to 
their  circumstances,  and  abide  by  the  consequences. 
Points  of  Favor. 
In  contra-distinction  to  the  objectionable  features,  accord- 
ing to  those  opposed  to  the  method,  the  following  may  be 
mentioned  as  points  in  favor  of  it.  It  is  not  necessary  that 
the  patient  be  taken  to  a  hospital,  asylum  or  sanatorium 
especially  equipped  for  handling  this  class  of  patients,  but 
treatment  can  be  instituted  at  the  patient's  home,  often  with 
but  little  if  any  interference  with  his  daily  routine  of  work. 
The  withdrawal  symptoms  are  not  so  conspicuous  as  in  the 
case  of  sudden  withdrawal,  and  with  proper  treatment,  can 
be  almost  entirely  prevented  or  overcome.  While  being  far 
from  recommending  this  method  in  all  cases,  I  do  not  hesi- 
tate to  state  that  in  the  light  of  our  present  knowledge  of 
remedies  for  carrying  the  patient  over  this  critical  period, 
the  method  is  decidedly  advantageous  and  occupies  a  place 
in  the  treatment  of  drug  addictions  which  is  distinctly  its 
own. 

THE  MODE  OF  SUDDEN  WITHDRAWAL. 

This  is  the  method  known  as  that  of  Levinstein,  and  con- 
sists of  suddenly  withdrawing  the  supply  of  morphine, 
imprisoning  the  patient  in  a  padded  cell,  and  allowing  him 
to  fight  the  fierce  battle  in  such  a  manner  as  he  may  be  able 
to  do.  Physicians  are  in  attendance  to  administer  stimulants 
in  case  of  collapse  or  impending  death.  Its  advantages  are 
claimed  to  be,  certainty  of  cure  and  rapidity  of  cure,  the 
struggle  being  over  in  from  four  to  six  days.  The  cruelty 
of  this  method  beggars  description.  Tongue  cannot  describe 
nor  pen  portray  its  horrors. 

Its  employment  is  an  infliction  of  a  punishment,  greater 
than  the  vast  majority  of  morphine  habitues  can  bear,  and 
if  collapse  or  death  does  not  ensue,  their  subsequent  condi- 
tion is  such,  that  a  relapse  is  practically  certain.  In  success- 
ful cases  the  rapidity  of  cure  cannot  be  denied,  but  its  dan- 


I/O  DRUG   ADDICTION. 

gers  and  probable  failure,  cannot  but  condemn  it.  It  is  a 
relic  of  the  past,  and  deserves  no  consideration  except  for 
condemnation. 

THE  MODE  OF  RAPID  WITHDRAWAL. 

When  the  condition  or  intelligence  of  the  patient  is  not 
such  as  to  class  him  among  those  to  whom  the  gradual  mode 
of  reduction  is  applicable,  the  rapid  method  is  recommended. 
Under  this  method  the  supply  of  the  drug  is  reduced  by  one- 
half  daily,  until  the  point  of  crisis  is  reached,  when,  unless 
threatened  by  collapse,  the  patient  is  given  no  more  mor- 
phine. Reductions  can  usually  be  made  for  several  days 
in  this  rapid  manner  until  the  drug  is  reduced  to  a  certain 
quantity,  without  material  inconvenience  to  the  patient,  but 
as  the  limit  of  reduction  is  reached,  abstinence  phenomena 
will  appear. 

Under  proper  treatment,  this  period  of  crisis  can  be 
passed  with  but  moderate  suffering,  although  it  is  rare  that 
patients  will  not  complain  considerably  during  it.  Twenty- 
four  to  thirty-six  hours,  will  usually  witness  the  disappear- 
ance of  the  symptoms,  and  the  patient  will  proceed  on  the 
course  to  recovery.  The  withdrawal  symptoms  are  to  some 
extent  increased  as  compared  with  the  gradual  method,  but 
are  infinitely  less  than  by  the  sudden  method.  From  six  to 
twelve  days  is  usually  all  the  time  required  to  render  the 
patient  free  from  the  desire  for  morphine,  although  subse- 
quent treatment  is  continued. 

The  advantages  or  points  in  favor  of  this  method  are. 
Certainty  of  success,  entire  absence  of  danger  of  collapse,  a 
short  duration  of  the  symptoms  produced  by  abstinence,  and 
the  short  time  required  to  effect  a  cure.  Wnen  patients 
cannot  be  depended  upon  to  co-operate  with  the  physician 
in  the  employment  of  the  gradual  reduction  method,  by  which 
the  drug  is  imperceptibly  reduced,  no  alternative  is  open. 
Rapid  reduction  must  be  practiced,  and  the  crisis  must  be 
endured.  The  rapid  and  gradual  reduction  methods  are  but 
different  degrees  of  the  same  plan,  and  in  either  case  the 


DRUG  ADDICTION.  171 

reduction  can  be  made  as  rapid  as  indicated  before,  or  to  a 
certain  extent  modified. 

DISTURBANCES  DUE  TO  WITHDRAWAL. 

When  the  supply  of  morphine  is  cut  off,  or  when  the 
reduction  has  reached  the  point  at  which  crisis  occurs,  certain 
symptoms,  previously  referred  to  as  abstinence  phenomena, 
will  appear.  One  of  the  principal  of  these  is  purely  psychic, 
purely  a  product  of  the  imagination.  It  is  the  fear  that  the 
patient  harbors  at  the  probability  or  possibility  of  future  suf- 
fering. This  fear  is  present  when  the  patient  is  absolutely 
comfortable,  with  no  wish  to  be  expressed  or  no  desire 
ungratified.  In  certain  individuals,  this  state  of  the  mind  is 
extremely  pronounced,  rendering  their  control  very  difficult, 
and  a  restoration  of  confidence  practically  impossible.  Hal- 
lucinations and  destructive  inclinations  frequently  are  mani- 
fested, furious  outbursts  of  rage  alternate  with  the  most 
piteous  appeals  for  relief,  attempts  at  suicide  or  murder  are 
indeed  not  beyond  the  possibilities. 

When  these  symptoms  first  appear,  before  the  disturb- 
ance becomes  too  great,  every  possible  effort  should  be  made 
to  retain  the  confidence  of  the  patient. 

Among  other  symptoms  of  withdrawal,  the  following 
are  the  most  prominent :  pain  in  any  part,  difficulty  in  swal- 
lowing, threatened  collapse,  delirium,  nausea  and  vomiting, 
diarrhoea,  cramps,  insomnia,  and  irritability  of  the  bladder 
or  incontinence  of  urine. 

Carefully  analyzed  all  the  true  symptoms,  due  to  the 
want  of  morphine  can  be  grouped  as  follows : 

(1)  Those  due  to  the  lack  of  the  customary  stimulus 
to  the  brain  cells,  which  stimulus  has  become  so  indispensable 
to  functional  activity  that  it  is  almost  akin  to  vital  force  itself. 
These  are  chiefly  restlessness  in  various  degrees,  sometimes 
amounting  to  actual  pain,  insomnia,  hallucinations,  and  the 
reflex  symptoms  previously  mentioned.  (2)  Those  due  to 
the  sluggishness  of  the  circulation  due  to  cardiac  weakness, 
caused  by  the  absence  of  the  customary  nerve  force  to  this 


17-2  DRUG    ADDICTION. 

organ.  These  are  the  various  degrees  of  collapse,  coldness, 
cold  and  clammy  perspiration,  muscular  weakness,  etc.  These 
symptoms,  due  to  either  of  these  causes,  also  appear  and  are 
modified  or  augmented  by  the  lesser  or  greater  disturbance 
of  either  the  brain  or  heart,  or  both  of  them  in  conjunction. 
(3)  Those  due  to  the  excessive  secretion  of  acid  in  the 
stomach. 

TREATMENT  OF  ABSTINENCE  SYMPTOMS. 

Since  the  publishing  of  the  last  edition  of  this  work,  in 
1 90 1,  considerable  new  light  has  been  cast  upon  the  treatment 
of  abstinence  symptoms,  and  in  fact,  as  to  avoid  or  ameliorate 
these  constitutes  the  painless  cure  of  the  addiction,  one  may 
say  that  the  entire  subject  stands  to-day  in  a  position  never 
before  occupied,  and  that  more  is  known  of  the  successful 
treatment  of  drug  addiction  than  ever  before. 

Treatment  of  the  abstinence  symptoms  necessarily  re- 
solves itself  to  a  treatment  of  the  cause.  While  formerly 
many  of  them  were  looked  upon  as  due  to  "nervousness,  con- 
stitutional disturbances,"  and  other  vague  terms,  I  am  now 
absolutely  certain  that  all  of  them  can  be  traced  to  one  or 
more  of  the  above  three  causes.  Since  recognizing  this  fact 
and  directing  treatment  to  the  organs  primarily  disturbed, 
as  soon  as  recognized,  a  very  considerable  portion  of  those 
symptoms  that  were  once  looked  upon  as  unavoidable,  are 
now  entirely  avoided  or  immediately  dispelled  on  their 
appearance. 

Some  of  the  secondary  and  reflex  symptoms,  when  they 
occur,  or  cannot  be  overcome  by  treatment  of  the  organ  from 
which  they  originate,  require  such  treatment  as  they  would 
demand  were  they  not  associated  with  the  treatment  of  the 
morphine  disease. 

Nitro-glycerine  has  an  action  during  the  morphine  re- 
duction craving  that  is  especially  desirable.  Apart  from  its 
action  on  the  heart  it  exerts  an  influence  on  the  disturbed 
brain  cells  that  produces,  in  a  mild  degree,  the  feeling  of 
morphine  euphoria.   In  doses  of  i-ioo  to  1-75  grain  it  relieves 


DRUG    ADDICTION.  173 

the  restlessness  and  craving.  Combined  with  amyl  nitrite 
inhalations  its  effect  is  increased.  It  is  useful  in  chilliness 
and  gives  rise  to  a  sense  of  warmth. 

Erythroxylon  Coca.  The  fluid  extract  is  valuable  for 
the  relief  of  restlessness.  Half  teaspoonful  doses  repeated 
as  required  will  afford  best  results. 

For  excessive  perspiration,  atropine  is  the  remedy. 
1-100  grain  twice  or  three  times  in  twenty-four  hours  will 
be  sufficient. 

For  insomnia,  Galvanism  is  an  excellent  remedy.  Neg- 
ative pole  to  the  forehead,  positive  pole  to  the  back  of  the 
neck.  Four  to  eight  cells  will  be  sufficient.  Sleep  often 
occurs  within  ten  minutes  of  its  application. 

As  the  craving  becomes  more  marked  the  heart's  action 
will  be  found  correspondingly  weaker.  A  strong  cardiac 
impulse  is  absolutely  incompatible  with  any  particular  degree 
of  suffering.  When  it  becomes  weak,  faint,  and  rapid,  spar- 
teine or  digitalis  must  be  administered  in  sufficient  doses  to 
maintain  what  may  be  considered  a  fair  normal  action.  The 
necessary  quantities  vary  in  different  individuals  and  cannot 
be  specifically  stated. 

Hyperacidity  of  the  Stomach.  This  distressing  symp- 
tom causes  more  genuine  uneasiness  and  misery  than  can  be 
imagined  by  one  who  has  not  seen  the  expression  of  those 
in  its  throes.  Pyrosis  almost  beyond  limit  is  frequently 
observed,  while  the  offensive  sour  breath  gives  ample  testi- 
mony that  this  symptom,  at  least,  is  not  imaginary. 

As  soon  as  the  first  sign  of  hyperacidity  manifests  itself, 
sixty  grains  of  Bicarbonate  of  Soda  should  be  given,  and 
repeated  in  similar  doses  as  often  as  necessary  to  keep  the 
stomach  sweet.  The  relief  derived  from  this  simple  remedy 
is  little  short  of  magical  and  is  not  limited  to  the  stomach 
alone,  but  the  entire  system  is  benefited  in  a  most  marked 
degree. 

The  Vapor  bath  taken  in  moderation  or  as  agreeable, 
will  be  found  valuable,  especially  at  night  before  retiring. 
I  do  not  altogether  recommend  that  it  should  take  the  place 


174  DRUG   ADDICTION. 

of  the  hot  tub  baths,  but  rather  that  as  an  agreeable  varia- 
tion it  will  prove  grateful  and  beneficial. 

Physostigmine  Salicylate,  a  salicylate  of  the  alkaloid  of 
the  Calabar  bean,  is  a  drug  that  exerts  a  particularly  happy 
effect  in  dispelling  the  symptoms  due  to  the  withdrawal  of 
morphine.  This  remedy  was  first  used  by  Prof.  Waugh,  of 
Chicago.  He  employed  it  in  doses  of  i-ioo  gr.  hypoder- 
matically.  He  states  that  it  produces  a  sense  of  comfort, 
fully  equal,  if  not  superior,  to  morphine. 

Pain  may  assume  the  neuralgic  type  and  follow  the 
course  of  the  greater  nerve  trunks,  it  may  affect  the  muscu- 
lar structures,  or  may  be  confined  to  the  bones.  When 
neuralgic  or  muscular  in  character,  the  chief  dependence  is 
placed  in  sodium  salicylate,  the  bromides,  and  when  possible, 
local  counter  irritation.  Collapse  requires  stimulants, 
brandy,  champagne,  strychnine,  nitro-glycerine,  or  sparteine 
for  the  heart,  hot  water  applications  or  faradism. 

Nausea  and  vomiting,  may  be  relieved  by  ingluvin,  bis- 
muth, oxalate  of  cerium,  or  if  carefully  used,  cocaine.  Diar- 
rhoea requires  bismuth,  acetate  of  lead,  extract  of  geranium, 
zinc  sulphocarbolate,  etc.  Cramps  and  pains  in  the  bones, 
are  much  relieved  by  hot  water  applications,  in  fact  a  bath 
in  water  as  hot  as  can  be  borne,  is  often  followed  by  a  com- 
plete cessation  of  all  the  disturbances.  No  limit  to  hot  water 
bathing  need  be  observed ;  patients  may  spend  as  much  time 
in  it  as  they  wish.  Delirium  calls  for  bromides,  or  what  is 
better,  Bromidia,  containing  potassium  bromide,  chloral 
hydrate,  hyoscyamus  and  indian  hemp.  Doses  may  be  regu- 
ated  according  to  effect  produced.  Trional  or  sulphonal  fre- 
quently produce  restful  sleep. 

Cystic  irritability  and  urinary  difficulties,  scalding,  incon- 
tinence and  neuralgia  of  the  bladder,  are  often  very  trouble- 
some. These  symptoms  alone,  have  been  known  to  cause 
the  patient  to  become  uncontrollable  and  decline  to  continue 
the  treatment.  Various  remedies  are  suggested  in  this  con- 
dition ;  belladonna,  triticum,  hydrangea,  boracic  or  benzoic 


DRUG   ADDICTION.  175 

acid,  sandalwood  or  saw  palmetto,  being-  remedies  that  may 
be  employed  with  good  results. 

Taking  as  a  basis  of  treatment  therefore  each  of  these 
organs,  the  brain,  heart  and  stomach,  it  is  scarcely  necessary 
to  point  out  that  no  absolute  schedule  of  treatment  can  be 
outlined,  and  right  here  let  me  say  by  way  of  parenthesis, 
that  this  is  the  weak  point  in  all  ready-made  treatments  or 
fixed  formulae.  No  two  cases  can  be  treated  alike,  and  the 
results  that  attend  the  use  of  any  proprietary  or  fixed  formula 
are  at  best  very  doubtful,  as  to  permanent  results. 

The  most  important  factors  being  heart  depression,  ner- 
vous irritability  and  hyperacidity,  the  relief  of  either  of  these 
conditions  may  alone  be  sufficient  to  enable  a  patient  to  get 
well  who  might  otherwise  be  unable  to  endure  the  crisis, 
yet  when  each  indication  is  simultaneously  met  by  a  remedy 
that  overcomes  the  cause  of  suffering,  all  unpleasant  effects 
are  frequently  entirely  avoided. 

Although  as  just  stated,  no  two  cases  of  drug  addiction 
can  be  treated  in  exactly  the  same  manner,  a  majority  can  be 
brought  to  a  satisfactory  termination  by  methods  of  treat- 
ment somewhat  similar.  In  the  treatments  hereafter  outlined 
I  wish  it  to  be  remembered  that  no  iron  clad  rules  can  be  laid 
down.  The  formulas  given  are  those  most  frequentlv  em- 
ployed, and  the  progress  of  the  treatment  should  be  regarded 
as  being  typical  of  a  satisfactory  case.  Variations  in  great 
numbers  abound.  Different  indications  must  be  met  as  they 
occur,  yet  on  the  whole,  after  carefully  reading  every  line  of 
this  entire  subject,  any  physician  will  be  able  to  successfully 
treat  this  class  of  diseases.  It  will  at  least  serve  as  a  path 
along  which  he  can  travel,  making  his  own  observations,  and 
as  he  wends  his  way,  let  him  occasionally  pause  and  record 
that  which  seems  new  and  interesting,  as  landmarks  for  those 
who  mav  come  after  him. 


I76  DRUG   ADDICTION. 

Heroin  and  Dionin. 

Both  of  these  drugs  remove  all  desire  for  morphine 
because  they  are  nothing  more  or  less  than  compounds  con- 
taining morphine,  and  the  idea  that  is  now  fast  gaining 
ground  that  these  drugs  can  form  a  basis  for  the  treatment 
of  morphine  addiction,  is  entirely  unwarranted. 

A  medical  man  quite  recently,  in  a  letter  announced  to 
me  with  great  joy  that  he  was  now  entirely  free  from  the 
cursed  drug,  morphine,  and  that  he  was  entirely  sustained  by 
a  quantity  of  heroin,  less  than  one-third  of  the  usual  quan- 
tity of  morphine  taken !  Compare  this  statement  to  that  of 
an  inebriate  who  finds  that  he  can  get  along  well  without 
whisky  when  he  uses  alcohol,  and  you  will  appreciate  the 
position  of  a  heroin  addict.  The  craving  following  the  use 
of  heroin  or  dionin  is  infinitely  greater  and  more  unmanage- 
able than  that  of  morphine.  It  is  indeed  second  only  to 
cocaine. 

Double  Addiction. 

When  morphine  is  associated  with  some  other  drug 
addiction,  the  first  indication  is  to  withdraw  the  additional 
stimulant,  no  matter  what  it  may  be.  In  the  case  of  alcohol 
there  is  usually'  but  little  trouble  in  discontinuing  it ;  indeed 
after  a  short  time  without  it  the  patient  is  usually  better  sat- 
isfied, as  morphine  seems  to  be  more  satisfying.  These  two 
drugs  are  to  a  certain  extent  antidotal  to  each  other.  Never 
attempt  to  increase  the  whisky  allowance  in  a  double  addic- 
tion and  expect  thereby  to  reduce  the  morphine  and  cure  the 
patient.  The  result  of  such  a  procedure  would  most  likely 
be  delirium  tremens. 

Cocaine  addiction,  in  addition  to  that  of  morphine,  can 
also  usually  be  given  up  with  little  or  no  craving.  Here  also 
the  morphine  becomes  more  satisfying.  Do  not  try  to  reduce 
the  morphine  while  reducing  the  cocaine.  Be  content  with 
doing  one  thing  at  a  time.     When  cocaine  alone  is  the  drug 


DRUG    ADDICTION.  17! 


for  which  there  is  a  craving,  a  more  difficult  proposition  is 
presented.  Here  it  is  sometimes  a  good  plan  to  substitute 
morphine  for  cocaine,  gradually  of  course,  until  no  more 
cocaine  is  needed.  The  cure  of  the  morphine  addiction  is 
then  conducted  on  the  same  plan  as  in  other  cases. 


Preparatory  Treatment. 

For  Opium  or  Morphine  Addicts. 

As  previously  stated,  the  extremely  debilitated  victim,, 
the  physical  wreck,  is  as  a  rule  incurable.  Take  as  an  exam- 
ple, a  person  that  is  only  partially  able  to  attend  to  his  per- 
sonal needs,  in  an  extreme  state  of  emaciation,  without  appe- 
tite, practical  paralysis  of  the  bowels,  living  only  on  the  drug 
which  has  almost  annihilated  his  cellular  structures,  and  it 
requires  no  great  degree  of  ordinary  intelligence  to  conclude 
that  the  last  ray  of  hope  has  fled. 

In  cases  in  which  these  changes  have  not  progressed  to 
that  point,  and  in  fact  in  all  cases  considered  curable,  I  have 
found  it  advisable  to  place  them  on  a  course  of  preliminary 
reconstructive  treatment  for  a  few  weeks  or  a  month  prior 
to  the  time  when  the  regular  treatment  is  instituted.  In 
addition  to  reconstruction,  special  attention  must  be  paid  to 
elimination. 

For  this  purpose,  cathartics,  salines,  diuretics  and  dia- 
phoretics are  indicated.  Calomel,  phosphate  of  soda,  acetate 
of  potassium  and  pilocarpine  are  valuable ;  by  their  use  the 
alimentary  tract  will  be  thoroughly  cleared  out,  the  torpid 
liver  will  be  stimulated,  the  secretions  of  the  kidneys  will 


1/8  DRUG    ADDICTION. 

become  more  profuse  and  the  skin  and  emunctories  aroused 
to  normal  action.  For  nerve  and  tissue  reconstruction,  cin- 
chona, nux  vomica,  phosphoric  acid,  gentian  and  valerian, 
used  according  to  the  requirements  of  the  case,  will  be  of 
excellent  service.  .  During  preliminary  treatment,  the  daily 
allowance  of  the  drug  can  often  be  very  materially  reduced 
without  any  inconvenience  to  the  patient. 

As  a  tissue  builder  and  reconstructive  agent  of  the  first 
order,  Protonuclein  (Reed  &  Carnrick),  in  doses  of  ten  to 
twenty  grains  a  day,  is  a  remedy  that  deserves  special  men- 
tion. Its  action  is  two-fold ;  it  stimulates  leucocytosis  and 
combats  the  action  of  pathogenic  organisms.  It  is  a  decided 
cell  stimulant  throughout  the  entire  organism,  promotes 
glandular  activity,  assists  assimilation  and  the  reconstruction 
of  disintegrated  cell  structure.  The  dose  must  be.  regulated 
to  the  needs  of  the  individual,  and  should  be  pushed  to  but 
little  less  than  the  point  of  toleration.  This  will  be  evidenced 
by  a  feeling  of  fullness  in  the  head,  throbbing  of  the  cerebral 
arteries  and  headache.  It  should  be  continued  for  at  least 
two  to  four  weeks,  according  to  condition  of  patient. 

Bearing  in  mind  that  in  a  drug  habitue  all  the  digestive 
organs  are  sluggish  and  lack  functional  activity,  one  of  the 
first  indications  is  to  relieve  them  and  promote  normal  action. 
By  so  doing  the  gradually  decreasing  morphine  energy  will 
not  cause  such  rapid  nor  so  marked  an  effect  and  discomfort. 
By  this  means,  in  addition  to  the  remedies  employed,  the  mild 
discomforts  which  in  the  aggregate  would  amount  to  positive 
suffering,  are  reduced  to  the  minimum. 

The  improvement  in  patients  of  this  class,  by  a  prelimi- 
nary course  of  treatment,  is  well  marked,  and  has  I  believe  a 
considerable  influence  on  the  treatment  proper.  In  giving 
directions  for  the  administration  of  the  following  remedies, 
and  rules  to  be  followed  in  conducting  the  treatment  to  a  suc- 
cessful issue,  many  of  the  points  already  brought  out  in  a 
general  way,  will  be  repeated.  If  the  details  should  seem 
unnecessarily  explicit  to  any  one,  let  him  remember  that  the 
minutest  details  are  sought  for  by  many  whose  experience, 


DRUG    ADDICTION.  1 79 

or  powers  of  perception  or  conception  are  less,  or  whose 
desire  to  be  sure  they  are  right  before  they  go  ahead,  is 
stronger  in  them,  than  in  him  who  is  disposed  to  criticise. 


Exercise. 

During  preparatory  as  well  as  during  the  treatment 
proper,  no  unnecessary  demands  should  be  made  on  the 
patient's  energy  or  upon  that  of  any  organ,  for  although  the 
organism  may  have  practically  been  restored  to  a  proper  bal- 
ance by  the  different  remedies  employed,  it  will  have  sufficient 
need  for  its  reserve  forces,  and  they  must  therefore  not  be 
squandered  on  useless  exercise  or  unnecessary  worriment. 
Exercise  is  best  taken  when  the  absence  of  morphine  is  felt, 
as  the  change  of  position  or  moving  about  has  a  tendency  to 
relieve  the  mind  of  the  thought  which  then  is  uppermost. 
After  each  dose  of  morphine  a  fictitious  energy  is  felt  and  it 
is  at  this  time  that  the  patient  will  express  desire  for  activity, 
but  if  this  is  done  the  comfort  and  ease  secured  by  the  drug 
will  be  of  but  short  duration,  and  the  want  of  stimulation  is 
felt  earlier  than  if  the  opposite  course  is  pursued. 


l8o  DRUG    ADDICTION. 


Typical  Methods  of  Treatment. 

IMPORTANT. 

Do  not  begin  treating  a  patient  for  drug  addiction  until 
after  you  have  read  every  word  of  the  chapter  on  Drug 
Addiction.  Two  to  five  readings  will  be  of  proportionate 
benefit.  It  will  give  you  a  broader  view  of  the  subject, 
details  will  be  impressed  upon  your  mind  which  you  will 
otherwise  overlook,  and  you  will  be  the  better  prepared  to 
meet  emergencies  as  soon  as  their  appearance  is  made.  I 
shall  not  consider  it  necessary  to  repeatedly  refer  to  the  impor- 
tance of  watching  the  three  vulnerable  points — the  brain, 
heart  and  stomach.  Specifics  for  the  alleviation  of  symp- 
toms due  to  perversion  of  the  nervous  and  circulatory  cen- 
ters cannot  be  indicated  as  positively  as  for  those  due  to 
hyperacidity  of  the  stomach,  and  in  addition  to  such  as  are 
mentioned  throughout  the  several  treatments  and  general 
consideration  of  the  subject,  let  the  practitioner  remembei 
that  the  entire  materia  medica  is  at  his  command.  Heart  and 
brain  tonics  and  sedatives  respond  with  much  the  same  activ- 
ity in  a  patient  tinder  treatment  for  drug  addiction,  as  for 
any  other  disease,  and  the  same  good  judgment  should  be 
exercised  according  to  indication.  For  hyperacidity  and  the 
symptoms  due  to  this  condition  we  are  better  prepared  to 
specialize,  for  but  one  remedy  need  be  considered — Bicarbon- 
ate of  Soda.     Bear  it  in  mind  always. 

It  is  impossible,  except  at  the  risk  of  tiresome  repetition, 
to  give  the  minute  details  under  each  treatment.  All  methods 
of  treatment  should  be  considered  as  being  but  parts  of  the 
whole,  being  but  different  routes  converging  toward  the 
same  goal.  In  lieu  of  personal  experience,  the  best  substi- 
tute is  a  thorough  understanding  of  the  knowledge  that  may 
be  gained  by  careful  study  of  the  subject. 


DRUG    ADDICTION.  l8l 

A  Gradual  Reduction  Treatment. 


An  Excellent  Method  of  Reducing  the  Drug  and  Sus- 
taining the  Nervous  and  Circulatory  System. 


This  method  of  treatment  illustrates  the  principle  of 
restoring  and  sustaining  the  nervous  and  circulatory  system 
in  advance  of  withdrawing  the  morphine  to  an  extent  that  is 
noticed  by  the  patient,  and  if  intelligently  administered, 
varied  according  to  the  requirements  of  each  patient,  the  last 
fraction  of  a  grain  of  the  drug  can  frequently  be  withdrawn 
before  the  patient  is  aware  of  the  fact  that  he  is  free  of  its 
influence. 

Special  attention  is  directed  to  the  necessity  of  avoiding 
too  rapid  reduction.  Frequently  failures  result  in  overesti- 
mating the  beneficial  action  of  the  remedies  employed,  after 
an  observance  of  the  apparent  smooth  course  of  the  treat- 
ment. Failures  are  to  be  guarded  against  equally  as  much 
on  account  of  their  psychic  effect  on  the  patient,  as  for  lost 
time,  labor,  etc.,  as  patients  who  have  lost  confidence  are  in 
most  instances  not  desirable  ones. 

Preliminary  treatment  as  previous  outlined  must  not 
be  neglected.  It  is  of  fully  as  much  importance  as  that  which 
is  to  follow ;  indeed  upon  it  often  depends  the  success  of  the 
issue  and  the  permanency  of  the  cure. 

After  attention  to  the  preliminary  treatment  the  quantity 
of  drug  consumed  is  reduced  to  the  amount  absolutely  neces- 
sary to  sustain  the  patient  without  suffering.  The  well- 
known  custom  of  patients  to  fill  themselves  up  with  morphine 
before  taking  a  cure,  must  be  borne  in  mind,  and  for  a  few 
days  but  little  is  done  besides  the  preliminaries,  except  to 
allow  the  morphine  which  the  patient  has  stored  within  him- 
self to  expend  its  force,  and  ascertain  the  quantity  required. 
Absolute  control  of  the  patient's  morphine  supply  must  be 
obtained,  with  the  full  assurance,  that  any  demand  will  be 
supplied    when    needed.     Under    this    reduction,    the    heart 


1 82  DRUG    ADDICTION. 

sometimes  becomes  weak,  but  a  few  doses  of  strychnine  or 
hydrastin,  will  remedy  this.  The  principal  point  to  bear  in 
mind  is,  to  keep  the  patient  on  as  small  an  amount  as  will 
keep  him  in  comparative  comfort,  and  yet  not  reduce  it  to 
such  an  extent,  that  he  will  be  miserable  before  the  hour  for 
the  next  dose.  The  interval  between  doses,  should  vary  from 
four  to  five  hours,  preferably  before  meals  and  bed-time. 
Appetite  and  rest  will  be  better  if  so  given.  It  is  useless  to 
expect  a  patient  to  either  eat  or  sleep  when  he  feels  the  want 
of  morphine,  and  nothing  conduces  to  a  rapid  and  easy  cure, 
as  a  good  appetite  and  restful,  refreshing  sleep.  When  the 
patient  is  ready  for  the  beginning  of  the  regular  treatment, 
the  quantity  of  morphine  absolutely  required  per  day,  is  care- 
fully noted,  and  from  1-6  to  1-4  of  this  quantity  is  given  at  a 
dose,  hypodermatically,  four  times  a  day,  thus  giving  him 
2-3  of,  or  the  whole  usual  quantity  in  a  day.  The  best  method 
of  regulating  this  is  to  make  a  solution  of  morphine  in  dis- 
tilled water,  thirty-two  grains  to  the  ounce,  each  fifteen 
minims  of  which  will  equal  one  grain.  To  illustrate;  if  a 
patient  requires  four  grains  of  morphine  per  day,  he  would 
receive  from  ten  to  fifteen  minims  of  this  solution,  four  times 
a  day,  which  would  give  him  either  two-thirds  or  one  grain 
at  a  dose.  Never  give  more  than  is  required,  and  never 
reduce  it  unless  it  can  be  done  without  the  patient  noticing  the 
difference. 

As  a  nerve  reconstructive  and  tonic,  the  following  solu- 
tion is  given  hypodermatically,  at  the  same  time  as  the  mor- 
phine solution  is  given : 

^      Strychnine,  alkaloid gr.  1-4. 

Atropine  Sulphate gr.  1-6. 

Sparteine    Sulphate gr.  iij. 

Hydrastine  Muriate gr.  vj. 

Aqua   Destil fl.  §  J- 

Mix.     Sig. 

Inject  fifteen  or  twenty  minims,  according  to  condition 


DRUG    ADDICTION.  1 83 

of  patient,  four  times  daily,  at  the  same  time  as  the  morphine 
is  given.  Regulate  the  dose  according  to  effect,  maintaining 
at  twenty  minims,  if  no  contra-indications  appear. 

Continue   the  morphine   solution   in   same   quantity   as 
used  at  the  beginning,  for  eight  or  ten  days,  until  the  patient 
feels  perfectly  comfortable,  and  has  no  wish  for  stronger 
doses.    This  feeling  should  always  prevail,  but  if  reduction 
is  begun  too  early,  the  patient  will  complain.    Eight  to  ten 
days  is  usually  the  earliest  time  that  a  reduction  is  attempted. 
The  first  reduction  is  made  by  giving  the  doses  each  one 
minim  less  than  formerly ;  not  reducing  each  dose  one  minim 
less  than  the  preceding  one,  but  one  minim  less  than  was 
given  before  the  reduction  was  made,  thus  giving  the  patient 
four  minims  per  day,  less  than  before.   If  this  is  borne  well, 
a  similar  reduction  can  be  made  in  three  or  four  days  there- 
after, and  so  on,  until  the  dose  that  was  given  at  the  beginning 
is  reduced  by  one-third.     Now  make  another  solution,  con- 
taining half  the  quantity  of  morphine  used  in  the  former,  and 
double  the  dose,  less  one  minim.    Thus  if  the  patient  was 
receiving  ten  minims  of  the  solution  containing  one  grain 
for  each  fifteen  minims,   he   would  now   receive   nineteen 
minims  of  a  solution,  containing  one  grain  to  each  thirty 
minims. 

Continue  on  this  solution  until  the  patient  is  sustained 
well,  and  reduce  by  one  minim,  each  third  or  fourth  day, 
until  the  patient  receives  but  one-half  of  the  dose  he  received 
at  the  beginning  of  the  second  solution.  Now  make  another 
solution,  just  half  as  strong  as  the  one  just  discontinued  and 
double  the  dose  in  minims,  less  one,  and  by  similar  reductions, 
reduce  until  the  patient  receives  but  1-120  of  a  grain,  when 
the  treatment  can  be  discontinued.  Use  the  tonic  all  along 
in  full  doses,  gradually  increasing  them  if  well  borne,  toward 
the  latter  part  of  the  treatment.  Do  not  inform  the  patient 
when  the  last  dose  of  morphine  is  given,  but  give  several 
injections  of  water  for  a  few  days,  before  informing  him 
that  he  has  taken  no  morphine  for  a  certain  time. 


184  DRUG    ADDICTION. 

Inspire  confidence  in  the  patient,  assure  him  of  relief  if 
he  needs  it,  and  never  reduce  to  such  an  extent  that  the 
reduction  will  be  felt.  Watch  the  secretions  and  keep  them 
as  nearly  normal  as  possible.  Treat  all  complications  as  indi- 
cated and  give  plenty  of  good  wholesome  food.  See  refer- 
ence to  diet  elsewhere.  If  hypnotics  are  needed,  as  will  be 
in  some  cases.  Bromidia  cannot  be  excelled.  This  treatment 
is  slow,  covering  in  certain  cases,  several  months,  but  its 
success  is  certain,  and  all  disagreeable  features  are  avoided. 
It  is  best  adapted  to  sanatorium  work,  or  in  cases  where  the 
physician  can  be  in  constant  attendance. 


A    Gradual    Reduction    Treatment 
Without  Hypodermatic  Injections. 

The  following  is  a  method  of  treatment  that  will  give 
satisfactory  results  in  selected  cases,  under  proper  super- 
vision. It  is  sometimes  difficult  to  satisfy  one  accustomed  to 
the  syringe  mania  by  administering  morphine  by  the  mouth. 
In  certain  cases  however  the  change  can  be  made  by  reducing 
the  amount  injected,  and  giving  the  quantity  taken  from  it, 
by  the  mouth,  and  slowly  increasing  the  proportions  until 
the  full  dose  is  taken  internally.  Frequently  a  larger  quan- 
tity will  be  required  when  taken  by  the  mouth  than  by  hypo- 
dermatic injection,  but  this  is  of  little  consequence. 

A  number  of  reports  have  come  to  me  stating  that  these 
formulae  were  used  for  self  treatment  with  the  most  satis- 
factory results. 

After  a  course  of  preliminary  treatment,  the  treatment 
proper  is  instituted.  By  the  method  of  gradual  reduction  as 
hereafter  detailed,  each  succeeding  dose  of  the  drug  is  les- 
sened in  a  manner  that  is  frequently  imperceptible.  During 
;his  process,  the  Tonic  Compound  builds  up  and  supports 


6    IV. 

fl. 

5  iss-ij 

fl. 

o  ss- 

fl. 

o  iij. 

fl. 

5  vj. 

DRUG    ADDICTION.  1 85 

the  nervous  system.  The  drug  Jamaica  dogwood,  an  ingredi- 
ent in  the  Opiate  Compound,  deserves  special  mention  as 
a  substitute  for  morphine  or  opium.  The  fluid  extract  of  this 
drug  would  often  give  as  good  results  as  opium  prepara- 
tions, if  prescribed  in  their  stead  for  the  relief  of  pain,  and 
in  the  treatment  for  opium  addiction,  its  use  is  very  often 
attended  with  the  happiest  results,  satisfying  the  craving 
quite  considerably. 

The  Opiate  Compound. 

If      Morphine  Sulphate. .  . q.  s., 

Sodium  Bromide 

Ext.  Jamaica  Dogwood.  . 

Ext.  Viburnum  Prunif  .  .  . 

Elix.  Ammon.  Valerianate. 

Elix.  Aromatic. q.  s.  ad. .  . . 
Mix.     Sig.     One  teaspoonful  three  to  five  times  daily. 

The  quantity  of  morphine  in  this  compound  will  depend 
on  the  amount  consumed  by  the  patient.  Sufficient  of  the 
drug  is  to  be  taken  and  added  to  the  other  ingredients  so  that 
each  drachm  of  the  compound  will  contain  the  quantity 
usually  taken  at  one  dose.  Thus  if  a  patient  were  taking  J^ 
grain  doses  of  morphine,  the  quantity  required  would  be  ^ 
grain  for  each  drachm  of  the  six  ounce  mixture,  or  twenty- 
four  grains.  The  method  by  which  reduction  is  best  and 
most  conveniently  accomplished,  is  as  follows :  Prepare  two 
bottles  of  the  above  compound  and  add  the  morphine  to  one 
of  them.  As  each  teaspoonful  is  taken  from  the  bottle  con- 
taining the  opiate,  the  bottle  is  replenished  with  a  teaspoon- 
ful of  the  bottle  without  the  opiate.  When  the  bottle  with- 
out the  opiate  is  empty,  another  one  is  prepared  and  the  pro- 
cess continued,  no  more  morphine  being  added. 

The  intervals  at  which  the  doses  are  to  be  taken,  should 
be  the  same  as  were  formerly  observed  between  doses  of  the 
drug,  gradually  increasing  the  interval  between  them,  accord- 
ing to  the  necessity  of  the  patient.    After  several  bottles  of 


1 86  DRUG   ADDICTION. 

this  size  have  been  emptied,  and  the  dose  thereby  increased 
to  an  infinitesimal  quantity,  the  same  compound  without  the 
opiate  should  be  continued  for  a  few  bottles  more.  In  con- 
nection with  the  above,  the  following  compound  is  adminis- 
tered.   It  is  known  as 

The  Tonic  Compound. 

1^     Tr.  Nux  Vomica, 

Fl.  Ext.  Passiflora  Incarnata, 

Fl.  Ext.  Avena  Sativa aa.  fl.  §  j. 

Tr.  Hydrastis  Canadensis, 
Fl.  Ext.  Erythroxylon  Coca, 

Fl.  Ext.  Cinchona  Comp aa  fl.  5  ij. 

Elix.  Aromatic,  or  Syrup,  .q.  s.  ad.  fl.  §  xlj- 

Mix.  Sig.  One  to  two  teaspoonfuls  every  four  to  six 
hours. 

Continue  this  compound,  with  the  other,  during  the 
entire  period  of  treatment.  The  time  required  to  effect  a  cure 
naturally  depends  on  the  condition  of  the  patient.  No  one 
should  begin  this  treatment,  unless  plenty  of  time  can  be 
given  to  it.  It  is  a  gradual  reduction  cure,  and  cannot  be 
completed  according  to  any  fixed  schedule.  If  the  patient  is 
in  circumstances  that  will  allow  the  employment  of  a  more 
rapid  mode,  there  is  no  reason  why  it  should  not  be  adopted, 
but  to  the  person  to  whom  careful  attention  to  the  treatment 
will  not  prove  laborious,  and  who  has  sufficient  confidence 
in  himself  and  his  physician  to  expect  a  cure  and  follow  direc- 
tions, the  treatment  is  admirably  adapted.  The  symptoms 
due  to  the  withdrawal  of  the  drug,  are  very  often  practically 
absent,  but  will  be  present  in  a  certain  percentage  of  cases, 
and  entire  freedom  from  them  should  not  be  promised.  They 
are  never  severe  and  can  easily  be  overcome  by  a  little  forti- 
tude. A  moderate  degree  of  stimulation,  brandy,  champagne, 
or  electricity  will  often  relieve  the  unpleasant  symptoms. 
Attention  to  the  heart  and  respiration  must  not  be  overlooked, 
and  irregularities  met  according  to  indications. 


DRUG    ADDICTION.  1 87 


Systematic  Gradual  Reduction 

The  Use  of  the  Alkaloids  oe  Hyoscyamus. 

The  value  of  the  alkaloids  of  hyoscyamus  in  the  treat- 
ment of  opium  or  morphine  addiction  is  incontrovertible ;  the 
hydrobromate  of  hyoscine,  and  hydrobromate  and  sulphate  of 
hyoscyamine  being  most  frequently  employed.  During  the 
past  year  the  discussion  of  the  value  of  hyoscine  and  its 
various  salts  has  been  occupying  a  somewhat  prominent 
place  in  many  medical  periodicals,  and  has  received  atten- 
tion from  some  of  the  most  eminent  therapeutists. 

Naturally,  when  men  like  Hare,  and  others  in  the  same 
class,  recognize  the  value  of  a  drug  and  deem  it  of  sufficient 
importance  to  contribute  to  medical  literature  on  the  subject, 
interest  is  promptly  awakened,  and  as  a  result,  hyoscine  is 
receiving  the  attention  its  peculiar  virtues  merit. 

Those  of  the  profession  who  have  either  of  the  former 
editions  of  this  work  have  been  acquainted  with  the  action 
of  this  drug  for  several  years,  as  I  mentioned  it  and  gave 
directions  for  its  administration  in  my  first  edition,  published 
in  1900. 

The  following  formulae  will  serve  as  a  guide  for  the 
treatment  of  opium  or  morphine  addiction,  using  hyoscya- 
mine in  combination  with  other  well  known  remedies. 

It  was  contributed  by  a  physician  whose  experience  with 
this  combination  has  been  large  and  satisfactory. 

Injection  No.  i. 

I£     Morphine  Sulphate  gr.  vj  orq.s. 

Codeine    gr.  vj. 

Caffeine gr.  xij. 

Aqua  Dest fl-  o  J- 

Mix.  Inject  twenty  minims  four  times  a  day,  before 
meals  and  at  bed-time. 


1 88  DRUG   ADDICTION. 

Injection  No.  2. 

3>      Hyoscyamine  Sulphate gr.  iss. 

Aqua  Dest fi.  %  j. 

Mix.    Each  two  minims  equals  1-160  gr. 
For  directions  see  later. 

Injection  No.  3. 

I£      Strychnine  Sulphate gr.  2-5. 

Aqua  Dest .    fl.  %  j. 

Mix.    For  directions  see  later. 

Before  retiring  at  night,  give  patient  two  compound 
cathartics  and  three  grains  of  blue  mass,  together  with  his 
usual  dose  of  morphine.  Next  morning  the  bowels  should 
move,  and  if  this  does  not  occur,  a  large  enema  is  given, 
which  will  start  a  copious  stool.  After  the  bowels  have 
moved,  not  before,  give  twenty  minims  of  No.  1,  and  one 
minim  of  No.  2  at  once,  injected  into  the  arm  or  leg.  He 
will  now  take  breakfast  and  pass  the  time  in  any  pleasant 
manner,  until  time  for  the  second  injection,  which  is  given 
just  before  dinner.  The  third  injection  is  given  before  sup- 
per, and  the  fourth  at  bed-time,  about  ten  P.  M.  Never  let 
patient  sleep  during  the  day.  Before  retiring,  a  few  mild 
cathartic  pills  are  given,  sufficient  to  cause  another  move- 
ment the  next  morning.  The  second  day,  the  quantity  of  No. 
1,  is  reduced  by  one  minim,  but  he  is  given  two  minims  of 
No.  2  and  two  minims  of  No.  3.  Follow  this  course  through 
the  day,  and  at  night  give  sufficient  cathartic  pills  or  calomel 
to  insure  a  good  movement  the  following  morning.  Follow 
this  course  every  night,  as  free  movement  of  the  bowels  is 
necessary,  and  never  start  the  injections  in  the  morning, 
until  the  bowels  are  moved.  The  third  day,  reduce  No.  1  by 
one  minim,  and  increase  No.  3  by  one  minim,  No.  2  being 
given  same  as  before,  two  minims.  No.  2  is  never  increased 
or  decreased  from  now  on,  but  as  No.  1  is  decreased,  No.  3 
is  increased.    Decrease  No.  1  by  one  minim  each  day,  and 


DRUG  -ADDICTION.  189 

increase  No.  3  by  one  minim  each  clay.  When  No.  1  has 
been  reduced  to  ten  minims,  some  signs  of  disturbance 
usually  appear,  for  which  asafoetida,  in  six  gr.  doses,  is  given 
five  or  six  times  during  the  day.  If  the  kidneys  do  not  act 
freely,  sweet  spirits  of  nitre  may  be  given.  If  the  reduction 
seems  to  be  made  too  rapidly,  reduce  it  more  slowly,  always 
increasing  No.  3  in  the  same  proportion  as  No.  1  is  decreased. 
When  the  reduction  has  reached  the  point  where  only  one 
minim  of  No.  1  is  given,  it  may  be  discontinued  entirely, 
still  giving  two  of  No.  2  and  twenty  minims  of  No.  3.  Now 
give  a  large  dose  of  epsom  salts  and  observe  the  inky  black 
material  that  passes.  At  night  a  hypnotic  may  be  required 
and  Bromidia  is  administered  in  half  to  one  drachm  doses. 
Continue  No.  2  and  No.  3  for  a  few  days,  two  minims  of 
No.  2  and  twenty  of  No.  3.  Supply  abundant  nourishment, 
beef  tea  and  cereals,  prepared  foods,  and  assist  digestion  by 
bitter  tonics,  gentian,  quassia,  columbo,  and  give  three  or 
four  times  a  day,  one  drachm  of  Tr.  cinchona  compound. 
This  latter  may  be  begun  as  soon  as  the  morphine  is  stopped. 
Supply  reconstructive  treatment,  hypophosphites,  iron  and 
protonuclein  as  needed,  gradually  decrease  the  quantities  of 
No.  2  and  No.  3,  and  give  the  injections  at  longer  intervals, 
or  the  No.  2  may  be  dropped,  and  the  strychnine  may  be 
given  by  the  mouth.  Caution  the  patient  in  regard  to  his 
bowels  and  advise  regular  habits. 

Note: — In  injection  No.  1,  sufficient  morphine  is  added 
so  that  20  minims  will  represent  the  usual  quantity  taken  at 
each  dose. 


lQO  DRUG   ADDICTION. 

A  Forty-Eight  Hour  Cure. 


For  Opium  or  Its  Alkaloids,  Cocaine  or  Chloral. 


The  Use;  of  Hyoscine. 


The  following  formulae  are  those  employed  by  the 
majority  of  the  quick  cure  institutes,  although  some  may  be 
slightly  altered  in  appearance  for  the  purpose  of  deceiving 
those  to  whom  the  ready  made  solutions  are  sold.  The 
cases  that  are  adapted  to  this  treatment,  are  the  young, 
recent  and  vigorous  addict  in  middle  life.  The  less  quantity 
of  opium  or  morphine  taken,  or  the  shorter  the  period  during 
which  it  has  been  taken,  the  quicker  and  more  certain  the 
cure.  Do  not  employ  this  treatment  for  old,  feeble  or 
debilitated  cases. 

Formula  No.  1. 

IJ      Hyoscine  Hydrobromate gr.  ss. 

Tr.  Rhus  Tox., 

Tr.  Apis  Mellificata aa  TTL  v. 

Sol.  Acid  Boracic,  2  % fl.  5  j. 

Mix.    Sig.    Use  Hypodermatically. 

Maximum  dose Tit  x. 

Minimum  dose TTL  v. 

Use  according  to  directions  which  follow. 

Formula  No.  2. 

1^     Hyoscine  Hydrobromate gr.   J/g. 

Strychnine  Nitrate gr.  j. 

Nitro-Glycerine gr.  %. 

Fl.  Ext.  Avena  Sativa fl.  %  ij. 

Elix.  Aromatic q.  s.  ad.  fl.  5  vj. 

Mix.    Sig:.   One  drachm  everv  four  to  six  hours. 


DRUG    ADDICTION.  19 l 

Directions  for  Use. 

Prepare  your  patient  by  giving  him  a  saline  cathartic, 
magnesia  sulphate  or  citrate.  Be  sure  to  have  the  bowels 
thoroughly  moved  before  beginning  the  treatment.  Then 
give  a  hot  bath,  an  alcohol  sweat  if  possible.  A  vapor  bath 
cabinet  is  useful  for  the  purpose.  Let  the  patient  abstain 
from  his  accustomed  drug  until  the  craving  becomes  urgent, 
when  you  will  give  Five  minims  of  formula  No.  I.  Wait  fif- 
teen minutes  and  give  Five  minims  more.  Wait  thirty 
minutes  and  give  Ten  minims  more.  The  patient  will  now 
complain  of  a  dryness  in  the  throat  and  will  fall  asleep, 
which  will  continue  three  or  four  hours.  (Should  these 
symptoms  appear  after  the  second  dose,  after  the  thirty 
minute  wait,  a  dose  of  Five  minims,  will  probably  be  suffi- 
cient to  cause  sleep.  If  it  does  not,  give  another  Five  minim 
dose  after  fifteen  minutes.) 

On  awakening,  the  patient  will  complain  of  feeling 
dizzy,  his  face  will  be  flushed  and  the  pupils  largely  dilated. 
About  four  hours  after  the  last  dose,  or  when  he  awakes, 
give  another  dose  of  Ten  minims.  From  now  on,  when 
awake,  the  patient  will  pick  at  the  bed  clothes,  grasp  at 
imaginary  things,  will  find  bugs,  say  funny  things,  may 
swear  or  pray,  sing  or  cry,  etc.  Do  not  be  alarmed  at  this, 
as  it  shows  that  the  patient  is  under  the  influence  of  the 
remedy,  undergoing  the  denarcotizing  process.  From  now 
on,  give  only  sufficient  doses  to  maintain  this  condition  for 
a  period  of  twenty-four  hours.  As  the  patient  now  passes 
out  from  under  the  influence  of  the  remedy,  he  will  either 
ask  for  his  accustomed  drug,  or  he  will  renounce  it  and  joy- 
fully proclaim  his  freedom. 

Should  this  renunciation  not  be  complete,  ask  the 
patient  whether  he  has  a  craving  for  his  accustomed  drug.  If 
the  answer  be  "Yes,"  the  denarcotizing  process  was  not  con- 
tinued long  enough,  and  it  must  at  once  be  resumed  in  such 
doses  as  are  required,  and  the  semi-intoxicated  condition 
maintained  for  another  twelve  hour  period.    Stop  the  treat- 


J  92  DRUG    ADDICTION. 

ment    again    until   patient   becomes    rational    and   be   again 
governed  by  his  answer. 

If  he  declares  himself  free  from  the  craving,  he  will 
have  no  further  desire  for  the  drug,  and  you  will  commence 
giving  formula  No.  2. 

But  few  cases  will  require  more  than  thirty-six  hours  of 
the  denarcotizing  treatment,  while  many  will  be  cured  in 
from  eighteen  to  twenty-four  hours. 

During  the  treatment  with  formula  No.  1,  the  patient 
will  vomit  large  quantities  of  bile,  which  must  not  be  stopped. 

Each  "time  bile  is  vomited,  the  patient  will  feel  better,  as 
it  is  by  the  action  of  the  liver,  that  most  of  the  waste  pro- 
ducts which  are  thrown  off  are  eliminated.  The  heart's 
action  usually  remains  about  normal,  but  should  it  become 
weak,  or  in  your  judgment  require  it,  give  a  hypodermatic 
injection  of  either  nitro-glycerine  or  strychnine  nitrate.  The 
former  is  indicated  when  the  body  is  cold.  The  average  dose 
of  the  former  is  1-100  grain,  and  of  the  latter  1-30  grain. 
Should  the  tongue  become  dry,  the  breath  fetid  or  perspira- 
tion profuse,  no  alarm  need  be  felt.  There  is  also  in  some 
cases  sneezing,  gaping,  free  salivation,  and  an  unpleasant 
odor,  which  may  become  nauseating  to  the  attendant.  Should 
the  respiration  become  slightly  accelerated,  no  notice  need 
be  taken  of  it,  but  should  it  become  labored,  a  dose  of  1-4 
to  1-2  grain  of  morphine  may  be  given.  This  will  not  now 
retard  the  treatment  but  will  soon  correct  the  breathing,  when 
the  treatment  can  be  continued  in  smaller  doses. 

During  the  treatment,  give  the  patient  all  the  cold  water 
he  wants  and  plenty  of  good  rich  milk.  Diet  is  referred  to 
elsewhere. 

The  Use  oe  Formula  No.  2. 

After  the  craving  has  been  removed,  and  the  patient 
has  renounced  the  drug,  give  one  drachm  of  formula  No.  2, 
and  repeat  the  same  dose  every  four  hours,  gradually  chang- 
ing to  six  hours,  as  the  patient  becomes  stronger.  This 
should  be  continued  for  from  three  to  six  days,  according  to 
the  individual  need  of  the  patient. 


DRUG    ADDICTION.  193 

The  most  common  complaint  after  being  cured  of  the 
opium  or  morphine  addiction  is  insomnia,  and  experience 
teaches  that  sleep  brought  about  without  the  use  of  hypnotics, 
is  most  beneficial  to  the  patient.  Cold,  warm  or  tepid  baths 
may  be  employed,  after  which  a  cold  compress  may  be  placed 
across  the  abdomen  and  held  there  by  means  of  an  oiled  silk 
bandage.  If  drugs  are  required,  I  advise  the  use  of  Bro- 
midia,  (Battle  &  Co.,)  in  half  to  one  drachm  doses. 

During  the  period  of  active  medication,  and  for  a  few 
days  afterward,  the  patient  should  be  undressed  and  con- 
fined to  his  room,  allowing  him  to  sit  up  or  lie  down  as  he 
pleases.  A  nurse  should  be  in  constant  attendance.  Baths 
should  be  given  daily  in  temperature  as  pleases  the  patient 
best,  or  which  gives  the  best  quieting  results.  Hot  baths 
are  usually  the  best.  Should  the  bowels  not  move  at  least 
once  in  two  days,  a  saline  should  be  given  as  required. 
Should  there  be  diarrhoea,  if  necessary  give  bismuth,  sub- 
nitrate  or  subgallate  as  needed.  After  a  few  days  the  patient 
regains  his  appetite  and  takes  on  flesh  rapidly.  In  adminis- 
tering these  remedies,  use  the  graduations  on  your  hypo- 
dermatic syringe  as  a  gauge  for  formula  No.  I,  and  gradu- 
ate or  medicine  glass  for  formula  No.  2.  This  treatment  is 
heroic,  but  not  dangerous  in  properly  selected  cases. 

In  speaking  to  the  patient  before  commencing  this 
treatment,  it  will  be  best  to  avoid  mentioning  the  semi- 
intoxication  which  the  remedy  produces,  as  some  will  object 
to  it.  It  should  however  be  borne  in  mind  that  it  is  the 
presence  of  this  condition  which  makes  it  possible  to  abruptly 
withdraw  the  drug  without  the  infliction  of  much  suffering, 
just  as  it  is  possible  to  perform  surgical  operations  painlessly 
under  the  influence  of  ether  or  other  anaesthetic.  It  is  always 
best  to  inform  the  friends  of  the  patient,  if  they  will  see 
his  condition,  that  such  will  be  the  effects  of  the  treatment, 
thus  showing  that  vou  are  familiar  with  its  action. 


194  DRUG    ADDICTION. 

A  Rapid   Reduction  Treatment. 


For  Opium  or  Its  Alkaloids. 


This  is  an  admirable  method  of  treatment  and  one  which 
will  show  a  large  percentage  of  cures  in  curable  cases.  The 
quantity  taken  or  the  length  of  time  that  the  addiction  has 
been  present,  makes  but  little  difference  in  the  final  results, 
as  it  has  been  shown  that  cases  taking  upwards  of  one 
hundred  grains  of  morphine  a  day  have  recovered  as  quickly 
and  as  easily  as  those  whose  daily  consumption  equals  but 
two  to  ten  grains. 

All  cases  are  adapted  to  this  treatment  except  the  feeble 
and  debilitated,  especially  if  over  sixty  years  of  age.  The 
treatment  must  be  given  under  the  physician's  direction,  or 
that  of  a  good  nurse,  and  the  patient  should  be  seen  several 
times  a  day.  In  giving  this  treatment,  no  special  course  is 
outlined  for  the  patient  to  pursue,  but  he  can  either  go  to 
bed,  lounge  about  or  spend  part  of  the  time  in  the  open  air. 
He  should  not  attempt  to  do  any  work,  nor  exercise  anv 
more  than  possible.  The  more  exercise  that  is  taken,  the 
more  the  tissue  waste,  and  the  consequent  call  for  more 
frequent  stimulation.  No  morphine  should  be  given  after 
the  treatment  is  begun,  unless  absolutely  required,  as  will  be 
shown  by  extreme  nervous  prostration.  The  greater  portion 
of  cases  will  not  require  any  of  their  accustomed  drug  dur- 
ing the  time  they  are  under  treatment,  but  are  fully  sus- 
tained by  the  remedy. 

Formula  No.  i. 

I£      Powd.  Ext.  Cannabis  Indica gr.  iv. 

Res.  Podophyllum gr.  iij . 

Atropine  Sulphate gr.   ^. 

Strychnine  Nitrate gr.   1-3. 

Mix.  Ft.   Caps,  or  Pil  No.  xvj. 

Sig.  One  pill  or  capsule  with  each  dose  of  the  follow- 
ing preparation. 


DRUG    ADDICTION.  195 

Formula  No.  2. 

]>      Fl.  Ext.  A  vena  Sativa fl.  5  j. 

Fl.  Ext.  Passiflora  Incarnata, 

Bromidia,   (Battle  &  Co.,) aa  fl.  §  iss. 

Spt.  Ammonia  Aromatic, 

Syr.  Lactucarium  Virosa aa  fl.  q  ij. 

Mix.   Sig.   Four  drachms  as  directed  hereafter. 

Directions  for  Using. 

The  night  before  commencing  the  treatment,  allow  the 
patient  to  take  his  usual  dose  of  opium  or  morphine,  and 
also  give  a  ten  grain  dose  of  calomel,  triturated  well  with  the 
same  amount  of  sugar  of  milk. 

This  will  start  the  liver  to  action,  which  is  highly  neces- 
sary. In  the  morning,  after  the  bowels  have  moved,  let  him 
have  his  usual  dose  of  drug  and  in  one-half  hour,  commence 
the  treatment  by  giving  one  pill  or  capsule  of  formula  No.  1, 
and  four  drachms,  (one-half  ounce)  of  formula  No.  2. 
Give  both  together  as  though  it  were  only  a  single  prepara- 
tion. Repeat  this  dose  every  three  hours  until  twelve  to 
fourteen  doses  have  been  taken.  Then  give  a  dose  every 
six  hours,  until  three  to  six  more  have  been  given,  or  as 
may  be  required. 

After  the  twelfth  or  fourteenth  dose,  give  one-half  to 
one  drachm  of  Fl.  Ext.  Passiflora  Incarnata  every  two,  three 
or  four  hours,  according  to  the  nervous  condition  of  the 
patient,  and  continue  until  twelve  to  fifteen  doses  have  been 
eiven.  Do  not  eive  the  Passiflora  until  formula  No.  2  is 
being  taken  at  six  hour  intervals,  when  it  should  be  given 
between  doses  of  same. 

Should  there  be  excessive  nervousness,  Fl.  Ext.  Avena 
Sativa  in  doses  of  twenty  drops  and  upward  every  three 
hours,  will  be  of  excellent  service. 

Should  the  bowels  become  inactive,  keep  them  moving 
with  calomel  and  small  doses  of  podophyllum  The  patient 
will  feel  relieved  after  each  passage. 


I96  DRUG   ADDICTION. 

After  the  Passiflora  (and  Avena  Sativa  if  necessary,) 
has  been  taken  for  thirty-six  to  forty-five  hours,  gradually 
stop  it,  and  when  the  doses  have  been  reduced  by  ten  minims 
each  dose  until  none  is  required,  the  treatment  will  have 
been  completed.  Should  insomnia  be  persistent,  and  the 
means  before  mentioned  fail,  half  to  one  drachm  doses  of 
Bromidia,  should  be  given.  This  preparation  has  a  peculi- 
arly effective  action  on  these  cases,  as  patients  awake  with- 
out the  usual  dullness  experienced  by  the  use  of  the  com- 
mercial bromides  and  chloral. 

If  during  the  treatment,  the  patient  should  become  more 
nervous  or  weak  than  is  thought  to  be  safe  by  the  physician 
in  charge,  small  doses  of  morphine,  (1-4  to  1-3  gr.)  may  be 
administered  every  fifteen,  twenty  or  twenty-four  hours. 
This  will  ease  the  patient,  but  the  treatment  must  then  be 
continued  somewhat  longer,  at  least  thirty  hours  after  any 
of  the  drug  has  been  given. 

Never  begin  the  treatment  until  the  bowels  have  moved 
and  the  alimentary  tract  is  clear  of  all  irritating  substances. 
Should  nausea  come  on  at  any  time  give  warm  water  and  in- 
duce emesis ;  it  will  add  to  the  comfort  of  the  patient.  Hot, 
cold  or  vapor  baths  may  be  given,  as  best  borne  by  the  pa- 
tient. Should  the  heart  become  weak,  or  drop  below  fifty 
per  minute,  give  digitalin  or  nitro-glycerine ;  the  latter  if  the 
body  is  cold. 

Persons  too  weak  and  debilitated  to  take  this  treatment, 
should  be  given  the  one  next  mentioned. 


DRUG    ADDICTION!  197 


A  Gradual  Reduction  Treatment. 


Specially    Recommended    for    Weak   and    Debilitated 
Subjects.    For  Opium  or  Its  Alkaloids. 


This  is  a  very  effective  method  of  treatment,  and  as 
above  stated  is  especially  valuable  in  old,  weak  and  debili- 
tated cases.  It  can  also  be  employed  in  the  treatment  of 
strong  and  vigorous  cases,  but  these  are  usually  anxious  for 
a  treatment  that  cures  more  quickly.  It  is  also  an  excellent 
treatment  for  those  who  wish  to  be  their  own  patients  as 
well  as  their  own  physicians ;  for  self-treatment.  While  it  has 
been  called  a  Gradual  Reduction  treatment,  it  is  not  always 
that  the  accustomed  drug  will  be  called  for,  and  consequently 
the  cure  becomes  in  such  cases  a  comparatively  rapid  one. 
No  opium  or  morphine  should  ever  be  given  during  the 
treatment,  unless  absolutely  required.  When  a  patient  is  well 
sustained  by  the  treatment  and  no  drug  is  required,  the  cure 
is  usually  effected  in  less  than  six  days,  while  in  those  who 
have  the  need  of  it,  and  who  take  small  doses  as  occasion 
demands,  may  prolong  the  treatment  to  twenty  or  even  thirty 
days. 

The  immediate  and  constant  attention  of  a  physician  or 
nurse  is  not  required  during  the  administration  of  this  treat- 
ment, but  one  or  two  daily  visits  should  be  made  by  the 
physician.  Especially  is  this  true  if  the  case  is  treated  on 
the  gradual  reduction  plan,  as  the  physician  should  have 
absolute  control  of  the  morphine  supply  of  the  patient,  and 
at  his  visits  should  administer  the  necessary  amount.  It  is 
hardly  necessary  to  add  that  the  visits  of  the  physician 
should  be  at  stated  intervals  and  that  punctuality  is  an  im- 
portant feature. 

The  patient  should  not  work  during  treatment,  but  it  is 
not  essential  that  he  be  confined  to  the  house.    The  direc- 


I98  DRUG   ADDICTION. 

tions  should  be  carefully  followed,  especially  the  instructions 
relative  to  the  reduction  of  the  doses  of  the  accustomed  drug. 
The  formulae  are  as  follows  : 

Formula  Xo.  1. 

I£     Tr.   Belladonna  lvs fl.  3  viij-xij. 

Fl.  Ext.  Hyoscyamus fl.  5  vij. 

Fl.  Ext.  Prickly  Ash  bark fl.  3  iv. 

Glycerine..    C.   P fl.  %  iij. 

Syrup  Simple q.  s.  ad.  fl.  5  ix. 

Mix.  Sig.  One  drachm  every  three  hours  as  directed 
hereafter. 

Note.  Increase  or  decrease  the  belladonna,  according 
to  effect.  Moderate  dryness  of  the  throat  and  dilatation  of 
the  pupil  being  indicative  of  sufficient  dosage. 

Formula  Xo.  2. 

R     Fl.  Ext.  Passiflora  Incarnata, 
Fl.  Ext.  Avena  Sativa, 

Tr.   Xux  Vomica aa  fl.   "%  j. 

Tr.  Hydrastis  Canadensis fl.  %  ij. 

Tr.  Cinchona  Comp q.  s.  ad.  fl,  5  vj. 

Mix.  Sig.  One  drachm  every  three,  four  or  six  hours, 
as  directed. 

Directions  for  Use. 

Nearly  all  morphine,  opium  or  laudanum  addicts  use 
more  of  the  drug  than  is  actually  required  to  keep  them 
comfortable.  For  a  period  of  three  or  four  days  ask  your 
patient  to  reduce  the  quantity  of  the  drug  to  the  lowest 
amount  that  will  sustain  him  without  suffering.  Give  him 
during  this  time,  one  drachm  doses  of  formula  No.  2  every 
four  hours. 

After  three  or  four  days  of  this  treatment,  during  which 
time  the  drug  is  often  very  much  reduced,  before  retiring  at 
night,  give  him  a  ten  grain  dose  of  calomel,  triturated  well 
with  a  like  quantity  of  sugar  of  milk.  This  will  stimulate 
the  liver  to  action  which  is  highlv  necessarv  in  the  treatment 


DRUG    ADDICTION.  199 

of  these  addictions.  The  following  morning,  after  the 
bowels  have  moved,  begin  with  formula  No.  i,  one  drachm 
every  three  hours,  and  give  formula  No.  2  every  three,  four 
or  five  hours,  according  to  the  nervous  condition  of  the 
patient. 

Formula  No.  1  should  be  given  every  three  hours,  night 
and  day,  although  one  dose  may  be  omitted  if  the  patient 
sleeps  and  awakes  without  a  strong  craving.  If  the  craving 
be  strong  on  awakening,  no  dose  must  be  omitted.  If  the 
patient  is  nervous,  restless,  afraid  or  melancholy,  formula 
No.  2  should  be  given  every  three  hours,  alternated  with  No. 
1.  No.  2  may  be  continued  night  and  day  as  -may  be 
required.  It  is  a  tonic  to  the  motor  nerves  and  sedative  to  the 
sensory. 

Some  patients,  generally  the  young  and  vigorous,  or 
those  who  used  but  small  quantities  of  opium  or  morphine, 
will  be  able  to  discontinue  the  use  of  it  as  soon  as  the 
administration  of  formula  No.  1  is  begun.  In  these  cases 
where  none  of  their  accustomed  drug  is  taken  during  the 
treatment,  continue  the  treatment  for  Sixty  hours,  after 
which  reduce  each  dose  by  ten  minims  until  none  is  taken. 
Formula  No.  2  may  be  given  in  full  doses  while  formula  No. 
1  is  being  reduced,  if  patient  shows  signs  of  increasing  ner- 
vousness, or  if  not,  it  may  be  reduced  in  the  same  manner. 
Formula  No.  2  may  be  continued  as  a  supportive  for  a  period 
of  a  week  after  formula  No.  1  is  discontinued,  in  full  doses 
three  times  a  day. 

Gradual  Reduction.  If  a  patient  is  not  perfectly  sus- 
tained by  the  treatment  as  above  given,  but  manifests  a  crav- 
ing for  his  accustomed  drug,  a  small  dose  of  morphine  may 
be  given  once  in  ten,  fifteen  or  twenty  hours.  Begin  with 
about  one-third  of  the  usual  quantity  taken  at  once,  and 
reduce  every  succeeding  dose  by  one-sixth  to  one-third.  Do 
not  repeat  unless  absolutely  necessary  for  the  fair  comfort 
of  the  patient.  Continue  the  treatment,  in  same  manner  as 
outlined  above,  until  the  patient  has  taken  none  of  his  drug 
for  sixty  hours  when  you  will  reduce  the  medicine  as  above. 


200  DRUG   ADDICTION. 

It    is    apparent   that   the   less   morphine   given    during   the 
treatment,  the  quicker  the  cure. 

If,  when  the  remedy  is  being  reduced,  a  desire  for  the 
drug  should  appear,  do  not  give  it  at  once,  but  return  to  the 
full  doses  of  the  remedies  and  continue  thus  for  twenty  to 
thirty  hours  longer,  when  the  reduction  process  may  again  be 
begun.  For  weakness  or  irregularity  of  the  heart,  or  should 
it  drop  to  less  than  fifty,  give  digitalis,  strychnine  or  nitro- 
glycerine, as  indicated.  The  bowels  will  generally  remain 
open,  but  should  constipation  be  present,  it  must  be  over- 
come by  the  use  of  calomel,  podophyllin  or  sodium  phos- 
phate. Dark,  inky  passages  will  occur  in  the  latter  stages  of 
the  treatment,  and  will  greatly  relieve  the  patient.  For 
insomnia,  if  the  bath  and  wet  pack  will  not  relieve,  half  to 
one  drachm  doses  of  Bromidia  should  be  employed  as 
required.  Baths  may  be  used  as  before  mentioned  under  the 
former  treatments. 


DRUG   ADDICTION.  201 


The  Mattison  Method  of  Treating 
Morphinism. 

Dr.  J.  B.  Mattison,  of  Brooklyn,  N.  Y.,  who  has  devoted 
thirty  years  of  his  life  to  the  treatment  of  drug  addiction, 
has  published  a  monograph  on  the  subject,  the  essentials  of 
which  are  contained  in  the  following  extract. 

In  offering  his  method  which  he  terms  the  American 
method,  in  contrast  to  the  cruel  and  torturing  sudden  and 
rapid  reduction  methods  of  Levinstein,  Erlenmeyer,  and  other 
European  specialists,  he  claims  both  originality  and  success, 
and  places  his  method  in  advance  of  any  yet  presented. 

His  method  is  a  mean  between  two  extremes — avoiding 
the  painful  ordeal  of  abrupt  disuse,  and  the  tiresome  delay 
of  prolonged  decrease, — and  is  based  on  the  power  of  certain 
remedial  resources  to  subdue  abnormal  reflex  action,  and 
secures  largely,  two  cardinal  objects — minimum  duration  of 
treatment  and  maximum  freedom  from  pain. 

It  consists  in  producing  a  certain  degree  of  nervous 
sedation  and  consequent  control  of  reflex  irritation,  by  means 
of  the  bromides,  more  specifically  the  bromide  of  sodium. 

In  obtaining  the  effects  of  this  drug,  he  secures  the 
influence  of  the  continued  administration  of  it,  giving  it 
twice  in  twenty-four  hours,  at  regular  intervals,  so  as  to 
keep  the  blood  continually  charged  with  it.  A  most  import- 
ant difference  exists  between  the  effect  of  this  mode  of  using 
it,  and  that  of  the  single  dose,  or  two  or  three  doses  given 
so  nearly  together  as  to  form  practically  one  dose.  In  the 
former  case  the  system  is  constantly  under  the  bromide  in- 
fluence, while  in  the  other  it  is  nearly  free  a  large  portion 
of  the  time,  due  to  the  drug  being  eliminated. 


202  DRUG    ADDICTION. 

As  the  desired  action  of  the  continual  administration  of 
this  drug  is  somewhat  remote,  four  to  six  days  usually 
elapsing  before  there  is  decided  evidence  in  this  direction, 
much  more  desirable  results  are  secured  by  its  employment 
for  several  days  prior  to  complete  discontinuance  of  the 
opium — meanwhile  gradually  reducing  the  opiate — than  if 
the  withdrawal  be  abrupt,  and  then  reliance  placed  on  the 
bromide. 

In  the  former  instance  the  maximum  sedative  effect  is 
secured  at  the  time  of  maximum  nervous  disturbance  from 
the  opium  removal,  and  its  counteracting  and  controlling 
power  is  much  in  excess  of  that  to  be  had  from  its  adminis- 
tration after  the  nervous  irritation  has  set  in. 

The  bromide  of  soda  is  preferred  for  the  reason  that  it 
is  more  agreeable  to  the  taste,  more  acceptable  to  the  stomach, 
causes  the  least  cutaneous  eruption,  and  much  less  muscular 
prostration  than  either  the  bromide  of  potassium  or  bromide 
of  lithium. 

As  all  the  bromides  in  powder  form,  or  in  strong  solu- 
tion, are  somewhat  irritant,  sometimes  causing  emesis  and 
always  delaying  absorption,  it  should  be  given  largely  diluted, 
never  with  less  than  six  or  eight  ounces  of  cold  or  carbonated 
water,  and  in  the  larger  doses,  giving  one  drachm  of  water 
for  each  grain  of  the  salt. 

To  secure  the  requisite  degree  of  sedation  within  a 
limited  time,  it  is  essential  that  the  bromide  of  sodium  be 
given  in  full  doses.  Failure  is  often  due  to  non-observance  of 
this  point.  The  initial  dose  consists  of  ten  grains,  twice 
daily,  at  10  A.  M.  and  10  P.  M.,  increasing  the  amount 
twenty  grains  each  day — giving  the  second  day  twenty  grains 
at  each  dose,  the  third  day  thirty  grains  at  each  dose,  the 
fourth  day  forty  grains  at  each  dose,  and  continuing  thus  in 
proper  cases,  until  the  maximum  dose  of  one  hundred  grains, 
twice  a  day,  is  reached. 

During  this  time  the  usual  opiate  is  gradually  reduced, 
so  that  on  the  tenth  day  it  will  be  entirely  abandoned.  A  de- 
crease of  one-fourth  to  one-third  of  the  usual  daily  quantity 


DRUG    ADDICTION.  203 

is  often  made  at  the  outset,  experience  having  proved  that 
habitues  are  almost  always  using  an  amount  in  excess  of 
their  need,  and  this  reduction  causes  little  or  no  discomfort. 

Later,  the  opiate  withdrawal  is  more  or  less  rapid, 
according  to  the  increasing  sedation,  the  object  being  to  meet 
and  overcome  the  rising  nervous  disturbance  by  the  growing 
effect  of  the  sedative. 

In  patients  who  are  weak  and  anemic,  a  tonic  course  of 
treatment  will  be  advantageous  in  advance  of  the  treatment 
for  morphinism,  in  connection  with  goed  food  and  hygienic 
measures. 

Patients  may  have  attempted  to  reduce  their  daily 
allowance  before  coming  for  treatment,  and  in  such  cases 
the  usual  large  reduction  at  the  outset  is  omitted.  The  con- 
dition of  others  may  be  such  that  no  reduction  will  be  allow- 
able for  two  or  three  days,  until  a  part  of  the  bromide  action 
has  been  secured.  With  all  patients  this  rule  governs.  Each 
case  is  a  law  unto  itself ;  and  the  length  and  amount  of  the 
bromide  giving  and  consequent  rate  of  opiate  decrease  is 
determined  entirely  by  individual  peculiarity,  as  shown  both 
before  and  during  treatment. 

If  surprise  should  be  expressed  or  objection  made 
regarding  the  large  doses  of  bromide  given,  it  must  never  be 
forgotten  that  we  are  not  to  be  governed  in  the  giving  of 
any  remedy  by  mere  minims  or  grains,  but  by  the  effect  pro- 
duced. Again,  one  result  of  opium  addiction  is  a  peculiar 
non-susceptibility  to  the  action  of  other  nervines,  necessitat- 
ing their  more  robust  giving  to  secure  the  desired  effect. 

Given  in  the  manner  described,  no  unusual  effect  is 
noticed  before  the  fourth  or  fifth  day.  Then  an  increasing 
drowsiness  appears  which  deepens  into  slumber  more  or  less 
profound,  to  such  an  extent  sometimes  that  it  is  difficult  to 
remain  awake.  With  this  is  an  aversion  to  exercise,  not 
solely  due  to  muscular  weakness  but  also  to  mental  lassitude. 
Sometimes  the  hypnotic  effect  is  not  very  decided. 

The  bromic  breath  is  sometimes  noticed.  There  may  be 
acne,  but  this  is  usually  absent.     The  renal  secretions  are 


204  DRUG   ADDICTION. 

often  largely  increased,  and  when  this  occurs,  indicating 
rapid  elimination,  the  sedative  effect  is  not  so  well  marked. 

Patients  with  serious  lesion  of  the  heart,  lungs,  or  kid- 
neys, should  not  be  treated  by  this  method,  and  debilitated 
patients  should  always  receive  the  tonic  course  previously 
referred  to. 

Having  secured  the  desired  sedation  and  reached  the 
point  where  all  opiates  are  discontinued,  the  reflex  symptoms 
are  met  by  codeine. 

As  a  rule  this  drug  is  not  needed  during  the  period  of 
decrease,  although  exceptionally,  a  dose  or  two  may  be 
required  the  ninth  or  tenth  day.  When  its  active  use  is  begun 
it  is  given  in  doses  of  one  or  two  grains,  every  three  to  five 
hours,  by  the  mouth  or  hypodermatically,  and  this  is  con- 
tinued for  eight  to  twelve  days,  gradually  lessening  the  dose 
or  increasing  the  interval,  till  no  longer  required. 

The  salt  of  codeine  usually  given  is  the  sulphate,  muriate 
or  phosphate. 

There  is  always  insomnia  after  the  discontinuance  of 
the  opiate.  This  Dr.  Mattison  overcomes  by  trional,  twenty 
to  thirty  grains  for  men,  and  twenty  grains  for  women,  at 
7  P.  M.,  on  the  tongue,  aided  if  necessary,  by  ten  grains  more 
in  three  hours.  It  may  be  followed  by  hot  water  or  milk. 
This  may  be  necessary  for  eight  or  twelve  nights. 

For  the  relief  of  unrest  or  neuralgia  he  gives  cannabis 
indica  in  doses  that  seem  large,  but  he  assures  us  that  he 
has  given  them  to  hundreds  of  men  and  women  without  pro- 
ducing toxic  effects  that  gave  him  any  anxiety.  He  gives  of 
Cannabis  Indica,  thirty  to  sixty  minims  of  Parke,  Davis  & 
Co.'s  or  Squibb's  fluid  extract,  or  one  to  four  grains  of  solid 
extract.  Small  doses  are  exciting  while  large  doses  are  seda- 
tive, quieting  and  harmless. 

He  also  uses  the  Turkish  baths  for  restlessness  and 
neuralgia.  Warm  baths  are  worthless ;  hot  baths  useful.  For 
diarrhoea,  when  it  occurs,  he  gives  hot  water  enemas,  zinc 
sulphocarbolate,  fluid  extract  of  coto,  bismuth  or  tannopin, 
and  if  all  fail,  a  full  dose  of  opium  by  the  mouth  or  bowel. 


DRUG   ADDICTION.  20$ 

This  always  controls  it,  gives  a  full  night's  rest  and  the 
diarrhoea  seldom  returns. 

He  also  recommends  galvanism,  nitro-glycerine  and 
bicarbonate  of  soda  in  the  same  manner  as  mentioned  under 
a  method  of  treatment  previously  given.  In  case  of  collapse, 
which  he  says  has  never  occurred  to  any  of  his  patients,  he 
would  give  immediately  a  full  dose  of  morphine.  The  indi- 
cations for  this  would  be  irregular  pulse,  livid  skin,  faint- 
ness  and  pallor. 

Dr.  Mattison  advocates  the  discontinuance  of  the  syringe 
as  soon  as  treatment  is  begun,  or  at  least  within  a  few  days, 
and  substituting  therefor  the  giving  of  morphine  by  the 
mouth.  This  removes  the  fascination  that  patients  seem  to 
have  for  the  syringe  and  prolongs  the  effect  of  the  mor- 
phine. The  acme  of  effect  is  reached  earlier  by  the  hypo- 
dermatic method,  but  it  also  disappears  earlier,  while  by  the 
mouth  the  effect  is  slower  but  more  persistent. 

Patients  injecting  six  or  eight  times  a  day  will  do  well 
on  four  doses  by  the  mouth. 

The  patient  is  not  informed  as  to  the  decrease  of  the 
opiate  nor  of  the  actual  time  when  it  is  entirely  stopped. 

During  the  decrease  patients  are  informed  that  if  the 
amount  allowed  is  not  sufficient,  more  will  be  given  on  appli- 
cation. This  being  the  case,  no  motive  exists  for  secret 
taking,  and  inspires  confidence. 

After  treatment  is  completed  and  the  patient  free  from 
the  use  of  the  opiate,  months  must  elapse  before  the  system 
is  restored  to  its  normal  status.  Premature  return  to  physical 
or  mental  work  will  imperil  the  prospect  of  permanency,  and 
should  be  avoided. 


206  DRUG   ADDICTION. 


Relapses. 


The  general  impression  seems  to  prevail  that  any  cure 
for  opium  addiction,  that  is  not  at  once  positive  and  perma- 
nent, is  not  worthy  of  recognition,  and  to  the  relapses  that 
occasionally  occur,  is  in  a  great  measure  due  the  unmerited 
condemnation  that  has  been  placed  on  any  treatment  for 
this  addiction,  by  many  men  of  the  profession.  This  is 
undoubtedly  an  error.  Are  not  all  physicians  familiar  with 
the  relapses  that  occur  after  an  apparent  cure  of  typhoid, 
catarrhal  or  other  fevers  ?  Are  not  surgeons  frequently  called 
upon  to  operate  a  second  or  even  a  third  time  on  cases  in 
which  apparently  no  doubt  existed  as  to  the  outcome  of  the 
first  ?  Because  a  certain  line  of  treatment  in  which  you  have 
unbounded  confidence  fails  to  perform  the  work  expected  of 
it  in  an  isolated  case,  do  you  forever  condemn  it  and  refuse 
to  use  it  again  ? 

To  condemn  any  treatment  because  its  action  is  not  uni- 
formly satisfactory,  is  to  condemn  all  the  means  at  the  com- 
mand of  the  physician,  the  surgeon  and  obstetrician.  If  one 
trial  fails,  pursue  the  rational  course  that  is  followed  in  any 
case,  if  after  convalescence  from  any  disease,  the  patient 
should  have  a  relapse.  Failures  and  relapses  are  not  always 
attributable  to  the  treatment  employed,  as  patients,  during 
treatment  and  after  a  cure,  are  often  responsible  for  the 
failure  to  obtain  results  that  are  in  every  respect  satisfactory. 

An  important  factor  in  determining  the  permanency  of 
a  cure,  is  the  cause  that  was  responsible  for  the  formation  of 
the  habit.  It  will  be  necessary  to  consider  this  point 
thoroughly,  as  if  the  same  conditions  which  caused  the  patient 
to  resort  to  the  use  of  morphine  are  still  present,  there  will 
be  a  strong  temptation  to  seek  relief  in  its  narcotic  effects 
again.  Special  attention  should  therefore  be  given  to  the 
removal  of  the  cause  underlying  the  first  resort  to  the  drug. 


DRUG    ADDICTION. 


207 

In  a  certain  number  of  cases,  an  occasional  craving  will  mani- 
fest itself  from  no  determinable  cause,  unless  it  be  the  occa- 
sional mental  reference  which  the  patient  makes  to  the 
buoyant  state  in  which  he  existed  while  under  the  effect  of 
the  narcotic,  contrasted  with  the  present  state  of  imperfect 
nerve  control.  Even  after  a  cure  has  been  effected,  some- 
times for  several  months  after,  the  patient  will  not  feel 
entirely  comfortable,  even  though  there  be  nothing  present 
that  could  properly  be  termed  a  craving;  it  is  a  peculiar 
loneliness,  absent  mindedness,  lack  of  energy  that  at  times 
makes  its  appearance,  and  the  patient  cannot  help  imagining 
the  delightful  sense  of  relief  that  he  could  obtain  bv  just  a 
single  dose  of  morphine.  For  this  reason  a  change  of  scene, 
change  of  occupation,  travel,  amusement,  in  fact  any  diver- 
sion, will  be  of  material  assistance  to  the  patient.  There  is  a 
peculiar  feature  in  this  connection;  the  seventh  month  after 
the  cure  seems  to  be  the  hardest  one  to  endure,  and  all  cured 
patients,  unless  they  are  absolutely  free  from  all  traces  of  the 
habit,  should  undergo  a  tonic  course  of  treatment  from  the 
sixth  to  the  end  of  the  seventh  month. 

Another  frequent  cause  for  a  relapse  is  insomnia.  With 
insomnia,  a  weakness  of  the  heart  is  frequently  noticed,  and 
when  this  is  the  case,  the  weakness  or  irregularity  must  be 
met  with  such  drugs  as  digitalin,  sparteine,  strychnine,  caff- 
eine or  cactus.  The  relief  of  the  cardiac  irregularities  is  often 
followed  by  refreshing  sleep. 

If  this  is  not  present  or  after  it  has  received  attention, 
the  insomnia  will  usually  yield  to  the  use  of  hypnotics,  baths 
or  wet  pack.  As  a  hypnotic  suitable  for  these  cases,  nothing 
excels  Bromidia,  (Battle  &  Co.)  The  action  of  this  prepara- 
tion is  especially  advantageous  in  the  nervousness  and  ex- 
haustion frequently  met  with,  especially  in  those  above  middle 
age.  The  dose  should  be  from  fifteen  drops,  frequently  re- 
peated, increased  to  one  teaspoonful  if  needed.  It  is  frequently 
beneficial  to  change  hypnotics  on  different  nights.  Do  not 
forget  the  baths,  with  cold  pack  on  abdomen  if  insomnia 
is  persistent. 


208  DRUG    ADDICTION. 


Diet. 

The  capricious  appetite  of  persons  addicted  to  the  use 
of  opium  or  its  alkaloids,  is  often  entirely  destroyed  unless 
special  attention  is  directed  toward  the  selection  of  food, 
especially  toward  the  latter  end  of  the  treatment,  and  for 
some  time  following  the  cure. 

Sometimes  the  appetite  returns  with  such  force  that  there 
is  danger  of  over-eating,  and  on  this  account  special  direc- 
tions should  be  given  to  avoid  it.  When  too  much  food  is 
taken,  even  though  the  appetite  demands  it,  it  is  usually  fol- 
lowed by  gastric  disturbances  and,  almost  without  exception, 
a  craving  for  the  accustomed  drug. 

During  the  treatment  it  is  a  good  practice  to  avoid  all 
solid  food,  limiting  the  diet  to  liquids,  prepared  foods  and 
fruits,  as  hereafter  outlined. 

Exception  may  be  made  when  one  of  the  methods  of 
gradual  reduction  or  home  treatment  is  employed,  whereby 
the  treatment  is  extended  over  a  period  of  two  or  three 
months.  In  these  cases  the  patient  is  more  gradually  brought 
away  from  the  influence  of  the  drug,  and  the  system  restored 
in  advance  of  entire  withdrawal. 

When  a  method  of  treatment  is  employed  in  which  the 
physician  or  nurse  are  in  constant  attendance,  as  in  sanator- 
ium or  hospital  practice,  when  a  rapid  cure  is  desired,  or  in 
any  case  in  which  the  appetite  fails,  and  the  stomach  becomes 
irritable  and  rebellious,  often  accompanied  with  nausea  and 
vomiting,  a  careful  dietetic  regimen  must  be  followed. 

Liberal  doses  of  bicarbonate  of  soda,  especially  when 
there  is  hyperacidity,  lime  water,  and  charcoal  will  often 
relieve  the  more  urgent  symptoms.  I  am  particularly  partial 
to  soda,  and  as  previously  stated,  place  much  reliance  on  it. 


DRUG    ADDICTION.  2O0 

For  extreme  irritability  of  the  stomach,  external  applications 
of  mustard,  chloroform,  or  ice  will  sometimes  relieve.  Inter- 
nally cocaine  may  have  to  be  resorted  to,  and  if  all  this  fails, 
a  full  dose  of  the  accustomed  drug  may  be  required  to  tide 
over  a  critical  period. 

A  strict  milk  diet,  for  several  days  or  a  week,  will  often 
overcome  the  more  prominent  symptoms,  yet  some  patients 
are  unable  to  take  milk  in  the  necessary  quantities,  either  on 
account  of  an  aversion  to  it  or  because  it  produces  bowel 
irregularities.  Taken  fresh,  it  will  cause  diarrhoea  in  some, 
while  others  will  be  constipated  if  it  is  taken  boiled. 

Ordinarily,  when  no  special  gastric  disturbances  are 
present  or  threatened,  fruit  and  fruit  juices  are  beneficial; 
vegetables  boiled,  and  seasoned,  are  allowed;  bread,  plain  or 
toasted,  biscuits  and  cereals  may  be  taken  as  desired,  due 
regard  being  observed  as  to  quantity. 

Beef  tea,  prepared  either  from  prime  lean  beef,  or  a  good 
extract  of  the  same,  is  grateful  and  nourishing.  It  may  be 
used  within  proper  bounds.  Food  should  be  taken  whenever 
its  need  is  felt,  but  eating  to  the  limit  of  capacity  is  always 
prohibited. 

The  prepared  foods  form  an  agreeable  and  nourishing 
diet  for  persons  undergoing  treatment  for  drug  addiction. 
My  experience  has  been  that  a  solution  of  many  of  the  per- 
plexing problems  relative  to  diet,  will  be  found  in  their 
employment. 

When  the  exclusive  milk  diet  disagrees  or  is  not  palat- 
able, such  foods  as  Horlick's  malted  milk,  Eskay's  albumen- 
ized  food,  Mellin's  food  or  Wampole's  milk  food  should  be 
employed.  These  foods  are  nutritious,  tax  the  digestive 
organs  but  little,  furnish  a  large  amount  of  nourishment  in 
comparison  to  the  quantity  taken,  and  are  quite  palatable. 

Bovinine  is  also  an  excellent  food,  in  many  cases  prefer- 
able to  beef  extracts,  beef  broths  and  similar  products.  When 
well  borne,  an  unusual  amount  of  nourishment  is  derived 
from  a  small  quantity  of  this  preparation. 


210  DRUG   ADDICTION. 

Oysters  and  clams,  to  those  fond  of  this  food,  are 
usually  acceptable,  and  when  prepared  with  plenty  of  rich 
milk,  form  excellent  diet. 

During  treatment  for  Inebriety  patients  are  usually  not 
troubled  on  account  of  a  lack  of  appetite,  nor  rebellion  of  the 
stomach,  but  on  the  contrary,  frequently  eat  more  and  feel 
better  than  before. 


INEBRIETY.  211 


INEBRIETY. 

Chronic  Alcoholism. 

A  lengthy  discussion  as  to  whether  the  excessive  use  of 
alcoholic  stimulants  is  a  disease  or  a  habit,  is  at  this  time 
unnecessary,  as  the  medical  profession  is  now  practically  a 
unit  in  conceding-  that  while  the  occasional  indulgence  in  the 
use  of  alcoholic  liquors  as  a  beverage  may  properly  be 
termed  a  habit,  it  speedily  becomes,  through  unwise  indul- 
gence, so  pronounced,  as  to  constitute  actual  disease,  mani- 
fested by  certain  morbid  phenomena.  To  the  laity  these 
phenomena  are  not  always  apparent  and  their  opinions  are 
formed  by  the  impressions  conveyed  to  their  minds  by  the 
occasional  or  frequent  sight  of  an  intoxicated  person,  in 
whom  they  see  personified  all  that  is  wicked  and  immoral, 
wholly  ignorant  of  the  pathological  changes  that  have  taken 
place  in  that  delicate  structure,  the  nervous  system  of  the 
inebriate.  Again,  the  temperance  advocate  and  total 
abstainer  are  strong  in  their  declarations  that  drunkenness  is 
a  mean,  low  and  disgraceful  habit,  from  which  any  ordi- 
nary person  can  free  himself  by  the  exercise  of  his  will  power 
alone,  while  their  deductions  are  offset  by  those  of  the  vic- 
tim himself,  who  maintains  that  he  is  afflicted  with  a  high- 
born, aristocratic  disease,  of  uncertain  nervous  origin,  for 
the  temporary  relief  of  which  alcoholic  beverages  have 
proved  themselves  a  sovereign  remedy. 

Among  the  laboring  classes,  those  whose  position  in  life 
calls  for  an  expenditure  of  vital  force  which  their  plain  and 
often  innutritious  diet  fails  to  furnish,  the  habitual  use  of 
stimulants  is  frequqently  due  to  their  discovery  that  alcohol 
will  supply  to  them  the  stimulus  needed  to  enable  them  to 


212  INEBRIETY. 

accomplish  a  greater  amount  of  work  than  they  would  other- 
wise he  able  to  perform.  The  step  from  a  custom  of  this 
sort  to  confirmed  inebriety,  is  short,  indeed. 

Among  the  higher  classes,  the  desire  for  alcohol  is  often 
the  abnormal  craving  of  an  impaired  and  degenerate  nervous 
system  for  something  that  will  stimulate  and  support,  in 
order  that  it  may  perform  its  functions  without  pain  or 
friction. 

The  desire  for  alcoholic  stimulants  is  undoubtedly  to  a 
certain  extent  hereditary;  a  virgin  fountain  fed  from  an 
impure  and  tainted  spring. 

This  heritage  of  depraved  blood  is  a  horrible  endow 
ment,  but  something  from  which  unborn  multitudes  cannot 
escape,  for  shall  not  the  sins  of  the  father  be  visited  upon  the 
children  even  unto  the  third  and  fourth  generation?    What 
a  dreadful  heritage !    What  a  frightful  possession ! 

The  careless  and  unthinking  multitude  drink  daily, 
perhaps  because  the  primary  effect  to  them  is  pleasing,  or 
perhaps  because  it  temporarily  satisfies  a  craving  which  they 
have  never  stopped  to  analyze,  and  in  the  very  face  of  the 
fact  that  they  almost  daily  see  the  death  of  some  person,  cut 
off  in  the  prime  of  life,  either  from  chronic  alcoholism,  or 
some  one  of  the  many  disorders  to  which  it  gives  rise. 

In  the  indiscriminate  use  of  alcoholic  liquors  physicians 
assume  a  responsibility  for  which  they  would  hesitate  to 
answer,  and  for  which  they  would  dread  to  be  held  account- 
able. While  alcohol  has  in  some  forms  of  disease  an  apparent 
therapeutic  value,  physicians  should  exercise  greater  care 
and  discrimination  in  advising  its  use,  as  habits  of  inebriety 
are  not  infrequently  directly  traceable  to  a  physician's  pre- 
scription. Then,  too,  it  should  not  be  forgotten  that  unques- 
tionable therapeutic  authorities  hold  that  alcohol  is  abso- 
lutely destitute  of  curative  power,  but  is  always  a  profound 
nerve  and  tissue  poison,  producing  first  an  exhilarating 
effect  which  is  later  followed  by  a  state  of  depression,  to 
counteract  which  a  further  supply  is  necessary.     Any  thera- 


INEBRIETY.  213 

peutic  effect  which  has  ever  been  claimed  for  alcohol  can 
be  obtained  by  the  administration  of  other  drugs,  the  action 
of  which  is  better  understood  and  better  controlled,  and 
which  are  certain  not  to  leave  the  patient  in  a  state  of  nerve 
hunger  for  which  alcohol  is  the  only  remedy,  and  which  the 
patient  will  not  be  slow  to  discover. 

Drunkenness  is  seen  in  two  forms,  thus  establishing 
the  theory  that  it  may  exist  as  a  psychological  disease  of  the 
mind,  or  as  a  well  defined  physiological  abnormality  of  the 
nervous  system. 

As  an  example  of  the  first  form  we  have  the  periodical 
drinker  who  wavers  between  two  extremes  ;  either  abstaining 
entirely  for  an  indefinite  period,  or  neglecting  everything, 
and  doing  nothing  but  drink,  drink,  drink  until  he  becomes 
so  sick  that  he  is  compelled  to  desist.  His  spree  always 
winds  up  in  this  manner,  and  the  thought  of  being  sick  and 
his  desire  of  becoming  well,  changes  the  current  of  his 
thoughts,  and  when  he  recovers  he  will  not  drink  again  until 
he  begins  to  think  of  it  again.  These  cases  are  primarily 
psychological  and  it  is  not  until  they  get  the  thought  of 
drink  thoroughly  riveted  in  their  minds,  that  the  inhibitory 
power  of  the  will  is  paralyzed,  and  the  first  drink  is  taken. 
In  a  short  time  he  feels  new  life  and  energy,  every  cell  in 
his  body  becomes  buoyant  and  produces  a  feeling  of  exhil- 
aration which  he  cannot  contain,  and  he  continues  to  drink 
until  he  is  no  longer  able  to  do  so. 

In  the  other  form  of  drunkennesss,  where  the  shattered 
nervous  system  demands  a  continual  stimulation  or  suffers 
collapse,  the  condition  is  entirely  different  from  the  former. 

The  continual  drinker  never  gets  sick  from  the  use  of 
liquor,  but  from  the  lack  of  it.  Without  his  customary 
"bracer,"  an  individual,  who  perhaps  holds  the  destiny  of 
nations  in  his  hands,  is  utterly  unfit  to  perform  the  slightest 
portion  of  his  daily  duty,  or  unable  to  write  his  own  name. 

This  form  of  drunkenness  is  usually  a  subsequent  stage 
of  the  former.     Periodical  stimulation,  repeated  with  inter- 


214  INEBRIETY. 

missions  that  in  many  cases  steadily  grow  shorter,  in  time 
tend  to  produce  the  nervous  state  which  characterizes  the 
second  form.  When  this  condition  is  not  produced,  as  is 
often  observed  in  men  who  have  indulged  in  numerous 
periodical  debauches,  the  nerve  centres  of  the  individual 
have  acquired  by  inheritance;  constitutional  perfection  per- 
haps ;  a  resistance  sufficient  to  prevent  the  degenerative 
changes  from  taking  place.  It  is  this  nerve  resistance  which 
saves  every  moderate  or  periodical  drinker  from  that  condi- 
tion in  which  stimulants  are  continually  demanded,  and 
which  limits  the  disease  to  a  psychological  one,  with  more 
or  less  constitutional  manifestations.  The  man  who  can  drink 
or  leave  it  alone,  usually  drinks.  He  will  drink  whenever 
he  thinks  of  liquor  if  he  has  the  opportunity.  That  he  does 
not  become  a  habitual  drunkard  is  not  due  to  his  will  power, 
but  to  his  inherited  resistance,  a  condition  which  he  cannot 
understand  but  which  nevertheless  enables  him  to  do  without 
stimulants  if  occasion  demands  it,  and  yet  does  not  suffer 
from  the  lack  of  them.  In  him  who  has  less  of  this  nerve 
resistance,  the  disease  gradually  progresses  and  steadily 
there  is  developed  the  nerve  center  degeneration  which  makes 
a  stronger  demand  for  stimulation,  renders  the  mind  less 
firm  and  consequently  more  easily  influenced  by  the  morbid 
craving,  and  constant  stimulation  becomes  a  necessity.  To 
overcome  this  craving,  treatment  must  be  directed  to  the 
reparation  of  the  shattered  nerves  and  impaired  vital  organs, 
which  brings  us  to  this  part  of  the  subject. 


INEBRIETY,  215 


TREATMENT. 


If  the  periodical  excessive  indulgence  in  stimulants 
were  entirely  psychological,  drug  treatment  would  necessarily 
be  useless.  This  is,  however,  not  the  case.  It  is  psycho- 
logical, or  practically  so,  in  such  persons  who  can  by  their 
own  efforts  discontinue  the  use  of  liquor.  In  these  cases  all 
that  is  necessary  is  to  prevent  the  thoughts  in  this  direction 
from  controlling  the  individual  and  obtain  his  promise  to 
avoid  his  former  associates,  to  remain  away  from  places 
where  liquor  is  sold,  and  if  possible,  with  promise  of  reward, 
give  him  an  object  to  be  attained  by  the  fulfillment  of  his 
promise.  In  the  young  this  can  often  be  brought  about  by 
the  promise  of  such  objects  as  they  desire  or  will  appreciate, 
while  in  the  older,  promises  of  employment  or  position  in 
society  may  be  made  conditional  upon  their  abstinence. 
Change  of  surroundings  or  occupation  is  frequently  of 
benefit  in  this  connection. 

In  the  more  advanced  cases,  where  in  addition  to  the 
psychological  phase  we  have  beginning  degeneration  of  the 
nerve  and  vital  forces,  more  than  moral  suasion  is  necessary. 

It  is  not  considered  possible,  by  the  use  of  any  combina- 
tion of  drugs  imaginable,  to  change  the  cell  arrangement  of 
any  individual  in  such  a  manner  as  to  remove  the  possibility 
of  his  becoming  addicted  to  the  use  of  alcoholic  stimulants, 
or  to  forever  destroy  the  taste  for  it  after  it  has  once  been 
established,  without  the  aid  and  co-operation  of  the  person 
directly  concerned.  No  one,  no  matter  what  treatment  he 
has  taken,  no  matter  what  the  claims  that  are  made  for  it, 
can  remain  cured  unless  by  the  practice  of  total  abstinence. 
The  taste  of  liquor,  and  the  desire  for  it,  in  the  majority  of 
cases,  once  foreign,  can  easily  be  acquired  primarily,  and 
very  much  more  easily  if  after  a  long  term  of  gratification 
of  this  craving,  after  a  temporary  cessation,  it  is  again 
encouraged.     Full   consent  and  willingness  on  the  part  of 


2l6  INEBRIETY. 

the  patient  is  therefore  an  indispensable  requirement.  Treat- 
ment for  this  addiction  can  only  assist  the  individual  who 
has  a  desire  to  be  freed  from  its  grasp,  and  make  it  possible 
for  him  to  gain  the  mastery. 

The  essentials  in  the  treatment  of  inebriety  are  Elimi- 
nation, Nutrition,  Suggestion,  Reconstruction,  and  when 
required,  Rest. 

For  elimination  the  mercurials  are  sometimes  used,  but 
salines  seem  to  be  more  satisfactory.  Large  quantities  of 
water  should  be  combined  with  them  so  that  the  emunctories 
which  have  failed  in  their  physiologically  appointed  work, 
the  congested  brain,  liver,  stomach,  intestinal  tract,  mucous 
membranes  and  skin  are  to  be  relieved  and  stimulated  to  their 
proper  functions. 

Nutrition.  In  the  treatment  of  inebriety  the  patient  is 
not  so  apt  to  lose  his  appetite  as  in  the  treatment  of  other 
addictions,  and  a  strong  nutritious  diet  can  usually  be  main- 
tained with  benefit.  If  the  appetite  is  capricious  or  the 
stomach  disordered  by  solid  foods,  beef  tea,  milk,  cereals,  or 
the  prepared  foods  previously  mentioned  under  Diet  in  Drug 
Addiction  may  be  given. 

Suggestion  consists  chiefly  in  cheering  up  the  patient, 
assuring  him  that  he  will  be  cured  and  relieved  from  the  need 
of  stimulants,  and  impressed  with  the  thought  that  he  will 
not  be  compelled  to  stop  drinking,  but  that  he  will  be  strong 
and  manly,  and  will  be  able  to  conquer  the  desire,  and  keep 
it  away  from  him. 

Reconstruction  is  begun  with  the  beginning  of  treat- 
ment. The  method  by  which  this  is  accomplished  varies 
with  the  treatment  employed,  but  as  a  general  rule  a  few 
weeks  preparatory  treatment  will  be  of  benefit. 

Rest,  if  necessary,  sleep,  change  of  surroundings,  hypo- 
phosphites,  beef,  wine  and  iron,  strychnia  compounds, 
calisaya  cordials,  egg  phosphates  and  tissue  building  reme- 
dies are  indicated  for  this  purpose. 


INEBRIETY.  217 

After  elimination  of  effete  material  from  the  tissues, 
toning  up  and  improving  nutrition,  and  reconstructing  the 
forces  of  a  weakened  heart  and  nervous  system,  the  real 
treatment  begins. 

The  question  is  often  asked,  is  a  sanatorium  necessary 
for  the  successful  management  of  cases  of  inebriety,  or  can 
a  home  treatment  be  successfully  employed.  The  answer 
is  a  qualified  one.  Every  physician  in  general  practice  and 
in  connection  with  it,  can  cure  a  certain  class  of  selected 
cases  without  confining  the  patient  and  without  recourse  to 
asylum  methods.  Generally  speaking,  the  only  cases  that 
require  sanatorium  treatment  are  those  who  have  no  good 
home  in  which  they  can  be  taken  care  of,  or  no  one  to  attend 
to  their  wants  and  wait  on  them,  or  those  so  thoroughly 
wrecked  by  liquor  that  they  are  unable  to  follow  the  physi- 
cian's instructions,  and  who  need  an  overseeing  hand  to 
keep  them  under  restraint. 

Various  methods  of  treatment  for  inebriety  have  been 
devised,  and  many  remedies  have  been  brought  forward  as 
specifics,  but  the  true  specific  has  never  yet  been  discovered 
and  never  will  be.  No  single  remedy  or  combination  of 
remedies  will  cure  all  cases.  Differently  tempered  and  con- 
stituted persons  require  different  treatment.  Inebriety 
must  be  treated  as  any  other  disease;  with  an  ultimate  and 
well  defined  object  in  view,  and  meeting  indications  en  route 
as  good  judgment  and  experience  may  dictate. 

Quick  cures  for  drug  and  liquor  addiction  have  in  recent 
years  appeared  in  considerable  numbers,  and  while  many 
of  the  profession  have  chosen  to  condemn  these  without  a 
trial,  others  have  taken  them  up  and  used  them  with  consid- 
erable success.  The  Quick  Cure  method  is  best  adapted  to 
sanatorium  work,  as  the  treatment  is  vigorously  applied  and 
requires  almost  constant  attention  from  physician  or  nurse. 
It  is  adapted  to  the  treatment  of  persons  who  are  continually 
under  the  influence  of  liquor,  not  necessarily  intoxicated, 
and  who  have  in  many  cases  not  sufficient  self  control  to 


2.1 8  INEBRIETY. 

permit  them  to  make  up  their  minds  as  to  whether  they  wish 
treatment  or  not. 

Similar  treatments  to  the  following  are  frequently  adver- 
tised to  the  profession,  which  if  not  identical  with  this,  are 
not  sufficiently  different  to  merit  the  investigation  and  ex- 
pense necessary  to  ascertain  their  exact  composition,  if  such 
is  at  all  possible.  Hyoscine  Hydrobromate  is  the  only  drug 
that  produces  the  symptoms  as  outlined  under  the  Forty 
Eight  Hour  Cure  for  morphine  addiction,  and  many  of 
the  advertised  remedies  produce  these  without  variation. 

After  attending  to  the  preliminaries  the  patient  is  placed 
on  the  following  formula  and  an  effort  made  to  lessen  the 
quantity  of  liquor  taken.  It  should  be  continued  from  ten 
days  to  two  weeks. 

Formula  A. 

T$     Hyoscine   Hydrobromate gr.   1-20. 

Strychnine  Nitrate gr.  j. 

Tr.  Hydrastis  Canad, 

Tr.    Valerian aa  fl.  §  iiss. 

Tr.  Capsicum fl.  §  ss. 

Tr.  Cinchona  Comp q.  s.  ad.  fl.  §  viij. 

Mix.    Sig.    Two  drachms  every  four  to  six  hours. 

Under  this  treatment  the  patient  will  usually  be  able  to 
get  along  with  a  much  less  quantity  of  liquor  than  was  his 
custom,  will  improve  in  appearance  and  general  health  and 
will  be  in  condition  to  receive 

Formula  B. 

I£     Hyoscine  Hydrobromate   gr.  j. 

Sol.  Boracic  Acid,  2  per  cent fl.  §  ij. 

Mix.     Sig.     Five  to  ten  minims  hypodermatically. 

Directions  for  use.  The  directions  given  for  the  use  of 
Formula  One,  under  the  Forty-Eight  Hour  Cure  for  Mor- 
phine and  Opium,  will  apply  to  the  use  of  this  formula  in  the 


INEBRIETY.  219 

treatment  of  inebriety.  They  are  practically  of  the  same 
composition.  Formula  A  is  discontinued  when  Formula  B 
is  begun,  but  is  resumed  again  as  hereafter  directed. 

Treatment  with  Formula  B  should  be  continued  for 
from  four  to  six  days,  but  it  is  not  essential  to  continue  it 
through  the  night,  but  may  be  discontinued  about  10  P.  M, 
and  resumed  in  the  morning.  After  four  days'  treatment, 
before  resuming  in  the  morning,  ask  the  patient  whether  a 
desire  for  drink  is  present,  and  as  long  as  the  answer  is 
"Yes,"  continue  the  treatment.  When  the  answer  is  "No," 
the  treatment  may  be  discontinued. 

This  class  of  patients  frequently  manifest  more  or  less 
destructive  inclinations,  and  should  they  become  unmanage- 
able, they  should  be  placed  under  restraint.  If  great  ner- 
vousness occurs  they  should  be  quieted  with  morphine  in 
doses  of  1-4  to  1-2  gr.  This  will  not  retard  the  treatment, 
as  they  are  not  addicted  to  morphine,  and  besides,  they  are 
taking  the  morphine  antidote.  After  a  short  sleep  they  will 
awake  refreshed  and  the  treatment  can  be  resumed.  Should 
the  pulse  rise  to  ioo  or  over,  do  not  crowd  the  treatment ; 
wait  a  short  time  and  it  will  be  reduced.  Continue  then,  in 
smaller  doses,  if  deemed  best.  Occasionally  a  patient  will 
be  met  with  who  requires  but  half  the  ordinary  doses,  while 
others  require  more  than  the  usual.  It  is  well  therefore  to 
use  the  remedy  according  to  effect.  The  semi-intoxicated 
state  should  be  maintained  in  a  moderate  degree  throughout 
the  treatment,  except  during  the  night,  as  before  noted, 
always  regulating  the  doses  by  the  effects  of  the  preceding 
one.  These  patients  do  not  as  a  rule  vomit  during  the 
treatment  and  retain  their  usual  appetite.  The  same  general 
rules  as  to  baths,  nurses  and  confinement  of  patient,  given 
under  the  before  mentioned  opium  treatment,  apply  to  cases 
of  this  nature.  After  the  desire  for  liquor  has  been  removed, 
and  the  patient  regained  his  normal  mental  condition,  he 
may  be  allowed  to  occupy  his  time  about  the  house  or  go  out 
walking,  care  being  taken  that  he  does  not  become  fatigued. 


220  INEBRIETY. 

Now  Formula  A  is  again  commenced  and  continued  for  sev- 
eral weeks  longer,  or  as  needed. 

This  treatment  is  a  very  successful  one,  having  cured 
cases  who  were  "graduates"  of  renowned  institutions.  It 
should  not  be  used  except  under  sanatorium  facilities,  or 
in  apartments  adapted  for  the  purpose.  For  general  use,  by 
physicians  in  general  practice  or  who  do  not  devote  any 
special  attention  to  the  treatment  of  this  class  of  cases,  the 
following  methods  are  more  suitable,  and  better  adapted  to 
their  facilities. 


The  Ideal  Inebriety  Cure. 

For  Liquor,  Wines  and  All  Alcoholic  Beverages. 

A  treatment  adapted  to  all  cases.  No  special  facilities 
required.  This  treatment  is  recommended  in  all  cases  where 
the  patient  is  willing  to  be  cured,  such  as  come  within  the 
reach  of  the  physician  in  general  practice,  who  usually  has 
neither  the  time  nor  facilities  at  his  disposal,  which  are  neces- 
sary for  the  correct  administration  of  the  treatment  pre- 
viously mentioned.  The  time  required  to  effect  a  cure  varies 
from  ten  to  twenty  days,  according  to  the  length  of  time  the 
patient  has  been  addicted  to  drink,  the  quantity  consumed 
and  his  physical  condition.  The  habitual  tippler,  the  indi- 
vidual who  drinks  three  to  thirty  times  a  day  without  becom- 
ing intoxicated,  but  whose  physical  condition  demands  a 
constant  and  oft  repeated  "bracer,"  requires  more  treatment 
than  the  person  who  indulges  in  a  periodical  debauch  and 
perhaps  for  a  month  afterwards  does  not  touch  liquor. 
Carry  one  of  the  latter  class  over  the  time  during  which  he 


INEBRIETY.  22  £ 

would  become  intoxicated  and  the  greater  part  of  the  battle 
will  be  won. 

The  "sickening  process"  has  always  been  a  closely 
guarded  secret  in  the  treatment  of  inebriety.  By  this  is 
meant  the  part  of  the  treatment  directed  toward  impressing 
the  patient  that  liquor  and  his  system  are  becoming  antago- 
nistic to  each  other.  This  is  not  accomplished  through  the 
medium  of  the  regular  treatment,  but  by  the  secret  substitu- 
tion of  an  emetic  at  the  proper  time.  This  emetic  is  usually 
Apomorphine. 

This  drug  is  given  at  the  usual  time  for  a  hypodermatic 
injection,  and  is  substituted  for  it.  The  patient  is,  of  course, 
not  informed  of  this  change.  When  it  is  given  in  this  man- 
ner, and  a  drink  of  liquor  shortly  afterward,  the  patient  will 
attribute  the  resulting  emesis  to  the  treatment  and  will 
become  convinced  that  the  treatment  is  doing  its  work. 
Sooner  or  later  he  will,  however,  begin  to  doubt  that  he  is 
being  benefited,  and  he  will  have  a  desire  to  see  whether  he 
still  cannot  retain  his  customary  beverage.  In  this  wish  he 
should  be  gratified  as  much  as  possible,  but  it  should  be 
arranged  that  the  drink  will  be  taken  at  about  the  time  when 
it  is  customary  to  give  a  hypodermatic  injection,  and  apo- 
morphine again  substituted.  The  result  will  of  course  be  as 
disastrous  as  the  first  attempt,  and  there  is  usually  no  further 
doubt  on  his  part.  Should  there  be,  the  same  procedure  is 
repeated.  Two  or  three  times  is  usually  sufficient.  The 
patient  should  have  sufficient  confidence  in  the  physician 
not  to  drink  during  the  treatment,  unless  when  allowed  to  do 
so,  but  he  may,  of  course,  furnish  his  own  whiskey. 

Formula  A. 

1^     Hypo.    Tablets    Gold    and     Sodium 

Chloride    aa  gr.   i-io. 

Sig.     One  tablet  injected  hypodermatically  three  times 
daily,  at  intervals  of  six  to  eight  hours. 


222  INEBRIETY. 

Formula  B. 

^     Atropine   Sulphate gr.   1-3. 

Strychnine   Nitrate gr.   1-2. 

Fl.  Ext.  Erythroxylon  Coca, 

Tr.    Cinchona   Compound aa  fl.  §  iss. 

Glycerine,  C.  P q.  s.  ad.  fl.  §  iv. 

Mix.  Sig.  One  drachm  every  four  hours,  during 
waking  hours. 

In  order  to  facilitate  the  cure  the  patient  should  be 
willing  to  quit  work  a  few  weeks  while  taking  treatment,  but 
it  is  not  necessary  to  confine  him  to  the  house.  Moderate 
exercise  is  beneficial.  Formula  B  can  be  entrusted  to  the 
patient,  but  it  must  be  taken  regularly. 

At  the  most  convenient  time  during  the  day  the  patient 
should  call  upon  the  physician  for  his  hypodermatic  injection 
of  Formula  A,  the  time  being  so  arranged  to  suit  both 
physician  and  patient.  At  breakfast,  after  noon  and  in  the 
evening  will  usually  be  convenient.  The  intervals,  as  stated, 
should  be  from  six  to  eight  hours.  Should  the  patient  be- 
come very  nervous  or  show  signs  of  delirium,  stop  the 
treatment  and  give  1-4  grain  of  morphine  sulphate  to  quiet 
him.  Resume  the  treatment  as  soon  as  thought  advisable 
and  continue  it  for  a  period  of  ten  to  twenty  days,  or  until 
the  patient  expresses  himself  as  feeling  free  from  the  desire 
or  need  of  liquor.  During  the  first  part  of  the  treatment, 
three  or  four  days,  small  quantities  of  liquor  may  be  allowed. 
Usually  one-half  ounce,  three  or  four  times  a  day.  This 
applies  only  to  the  continual  drinker,  and  not  to  the  period- 
ical, as  the  latter  can  well  do  without  it.  After  four  days  of 
treatment,  in  all  cases,  at  one  of  the  regular  calls  for  a 
hypodermatic  injection,  ask  him  whether  he  has  a  desire  for 
liquor.  The  continual  drinker  will  probably  say  he  has,  and 
if  he  has  been  taking  some  in  small  doses,  tell  him  you  would 
like  to  see  him  take  a  good  big  drink,  such  as  he  was  accus- 
tomed to  take.  If  he  has  not  taken  liquor  during  the  treat- 
ment, this  remark  will  be  omitted,  but  whether  he  says  he  has 


INEBRIETY.  223 

a  desire  or  not,  tell  him  you  would  like  to  see  whether  the 
treatment  is  acting  properly,  whether  it  is  strong  enough  or 
whether  it  has  already  produced  an  antagonism  in  his  system 
toward  liquor. 

Now,  instead  of  giving  him  the  usual  injection  of  For- 
mula A,  substitute  i-io  grain  of  Apomorphine,  and  follow  it 
within  a  few  minutes  with  the  drink.  Never  give  the  drink 
first,  as  something  might  occur  which  would  delay  or  pre- 
vent the  giving  of  the  apomorphine,  and  he  would  thus  find 
no  untoward  effect  from  the  liquor.  If  the  apomorphine  is 
given  first  and  the  drink  delayed  too  long,  so  that  nausea 
occurs  before  the  liquor  is  given,  it  can  be  attributed  to 
another  cause.  Due  attention  should  be  paid  to  these  details 
and  to  have  everything  ready.  Have  a  basin  or  vessel  con- 
veniently hidden  near  by,  so  that  the  patient  will  not  know 
that  you  made  preparations  for  what  will  occur,  and  wait  for 
developments.  If  the  dose  was  large  enough,  free  emesis 
will  occur  in  a  short  time.  Should  it  not  cause  vomiting, 
merely  nausea,  tell  him  that  the  treatment  is  acting  all  right 
and  that  after  a  few  days  more  treatment,  he  can  probably 
not  retain  liquor  but  would  have  to  vomit.  In  a  few  days 
repeat  the  experiment,  taking  precaution  to  give  somewhat 
of  a  larger  dose,  regulating  it  according  to  the  effect  pro- 
duced by  the  former  dose.  Tartar  Emetic  is  sometimes  used 
for  this  purpose,  mixing  it  with  the  liquor,  but  this  allows 
the  patient  to  form  the  opinion  that  you  have  drugged  his 
liquor,  and  thus  his  confidence  in  you  will  be  shaken.  By 
the  other  method  he  may  furnish  his  own  liquor.  Caution 
him  not  to  drink  unless  in  your  presence.  Examine  his 
heart  after  he  has  taken  the  drink  and  tell  him  that  it  must 
be  carefully  watched  when  he  takes  a  drink,  as  it  might 
need  immediate  attention.  Impress  upon  him  that  should 
he  drink  while  away  from  you,  his  heart  might  suddenly 
need  attention  and  as  you  would  not  be  at  hand  the  results 
might  be  unpleasant.  The  reason  for  these  admonitions 
are  obvious. 


224  INEBRIETY. 

After  he  has  been  thoroughly  sickened  several  times 
he  will  probably  refuse  to  touch  liquor,  even  the  smell  or 
sight  of  it  is  likely  to  produce  nausea.  Do  not  hesitate  to 
make  him  extremely  sick;  the  nearer  death  he  will  think 
himself,  the  more  certain  the  cure. 

Both  formulae  are  given  in  conjunction  during  the  ten 
to  twenty  day  period,  but  after  the  disgust  for  liquor  has  been 
firmly  established,  and  the  patient  seems  to  be  getting  along 
well  without  the  use  of  stimulants,  the  injections  may  be 
discontinued,  but  the  remedy,  Formula  B,  should  be  con- 
tinued for  a  week  or  more  afterward.  After  the  sickening 
process  is  begun,  all  liquor  should  be  discontinued.  The 
bowels  usually  remain  normal,  but  if  constipated,  use  sodium 
phosphate,  plenty  of  it ;  nothing  else,  except  all  the  water  he 
can  drink.  After  a  cure,  do  not  fail  to  impress  your  patient 
with  the  necessity  of  avoiding  the  association  of  intemperate 
companions,  the  frequency  of  saloons  or  bar-rooms,  and 
never  to  touch,  taste  or  handle.  Tell  him  that  as  he  once 
acquired  the  taste  and  desire  for  liquor,  he  can  do  so  again, 
but  as  he  is  free  from  it  now,  he  should  assert  his  manhood 
and  conquer  his  bitterest  enemy. 

This  treatment,  properly  administered  to  a  person  willing 
to  be  cured,  who  will  co-operate  with  the  physician  and  obey 
instructions,  will  do  wonderful  work,  and  cannot  be  too 
highly  recommended. 


INEBRIETY.  -225 


A  Home  Cure  for  Inebriety. 

There  is  more  or  less  of  a  demand  for  a  treatment  for 
habitual  drunkenness,  which  can  be  taken  or  administered 
without  the  direct  supervision  of  a  physician,  but  it  is  evident 
that  such  a  treatment  can  at  best  only  assist  an  individual 
who  will  make  an  honest  effort  to  overcome  the  recurrent 
desire  for  stimulants.  In  this  connection  a  few  words  may 
be  said  in  reference  to  the  numerous  home  cures  which  are 
advertised  as  specifics  for  drunkenness.  Some  of  these,  the 
majority  perhaps,  are  said  to  be  capable  of  eradicating  the 
desire  for  liquor  and  establish  an  antagonism  against  it, 
without  the  consent  or  even  knowledge  of  the  person  to 
whom  it  is  administered.  These  claims  are  in  direct  opposi- 
tion to  the  teachings  of  the  best  authorities  on  diseases  of  the 
nervous  system  and  entirely  contrary  to  the  experience  of 
physicians  who  have  made  the  treatment  of  chronic  alcohol- 
ism a  special  study  and  treated  hundreds  of  cases.  It  is 
quite  probable  that  the  majority  of  these  claims  are  fraudu- 
lent, and  in  many  instances  devised  to  ensnare  the  unfortunate 
wives  and  children  of  drunkards,  and  extract  from  them 
the  little  means  they  manage  to  possess.  Any  drug  which 
can  so  affect  the  nervous  structure  of  a  person  that  a  desire 
and  craving  for  liquor  can  be  eradicated  without  the  consent 
or  assistance,  or  even  against  the  will  of  the  person  to  whom 
it  is  given,  must  be  powerful  indeed;  probably  poisonous, 
and  if  so,  dangerous.  Some  of  them  are  however  claimed 
to  be  "entirely  harmless."  and  this  statement  I  will  not  dis- 
pute.    It  is  probably  true. 

The  following  method  of  treatment  commends  itself  to 
the  ordinary  cases  of  habitual  drunkenness,  and  will  afford 
substantial  assistance  to  any  one  possessed  with  an  honest 
desire  to  be  freed  from  the  craving  for  stimulants,  and  who 


226  INEBRIETY. 

will  make  an  effort  in  that  direction.  To  the  person  who  is 
unable  to  make  up  his  mind  whether  or  not  he  wishes  to  quit, 
its  action  will  serve  no  purpose.  The  more  moderate  the 
drinker  and  the  less  quantity  consumed  during  the  intermis- 
sion between  the  periodical  debauch,  the  easier  will  be  the 
cure.  This  treatment  is  not  as  powerful  nor  as  rapid  as  the 
foregoing,  consequently  the  hardened  inebriate,  the  one  who 
is  unable  to  control  himself  or  exercise  any  will  power,  will 
make  better  progress  under  the  former.  As  a  preliminary  to 
either  of  the  preceding  treatments,  it  is  of  value. 

Formula  A. 

I£     Atropine  Sulphate gr.  ss. 

Strychnine  Nitrate gr.  j . 

Tr.  Capsicum   fl.  o  ij 

Tr.  Pulsatilla , fl.  •">  iij. 

Fl.  Ext.  Erythroxylon  Coca. 

Tr.  Hydrastis     Canadensis aa  fl.  5  ij. 

Tr.  Serpentaria   fl.  ;>  j. 

Tr.  Cinchona  Compound fl.  %  iij. 

Elixir  Aromatic q.  s.  ad.  fl.  §  xij. 

Mix.  Sig.  Two  drachms  before  each  of  the  three  daily 
meals. 

Formula  B. 

B     Fl.  Ext.  Passiflora  Incarnata fl.  §  iij. 

Fl.  Ext.  Avena  Sativa fl.  §  ij. 

Elixir  Aromatic q.  s.  ad.  fl.  §  vj. 

Mix.  Sig.  One  drachm  at  9  A.  M.,  3  P.  M.  and  before 
retiring,  or  about  9  P.  M. 

Continue  both  formulae  for  four  to  eight  weeks,  accord- 
ing to  the  progress  of  the  case.  Patients  need  not  stop  work 
during  treatment. 


INEBRIETY.  22/ 

Other  Methods  of  Treatment  for 

Inebriety. 
j 

In  the  following  pages  other  and  well  known  methods 
for  treating  inebriety  will  be  detailed,  all  of  which  are  cred- 
ited with  sufficient  merit  to  warrant  their  use.  Some  of 
them  have  had  their  origin  and  are  successfully  employed 
in  the  practice  of  physicians  of  the  highest  professional 
attainments,  men  who  have  given  the  subject  much  study 
and  attention,  and  whose  objects  in  giving  them  to  the  pro- 
fession at  large  is  none  other  than  to  encourage  more 
thorough  investigation  and  attain  more  definite  results. 


Bellevue  Hospital  Treatment. 

Over  four  thousand  cases  of  acute  alcoholism  are 
received  in  Bellevue  Hospital,  N.  Y.,  every  year.  A  certain 
percentage  of  these  express  a  sincere  desire  to  be  relieved 
from  the  tendency  they  have  to  indulge  in  periodical 
debauches,  and  to  such  the  following  treatment  is  given.  It 
is  the  result  of  ten  years'  experience  in  the  care  of  these  cases. 

After  the  effects  of  an  acute  attack  of  alcoholism  have 
disappeared,  the  following  hypodermatic  injection  is  given. 
Each  dose  contains : 

R      Strychnine  Nitrate gr.   1-15. 

Atropine  Sulphate gr.   1-300. 

Distilled  Water 1U  x. 

Mix.  Sig.  Inject  three  times  a  day,  the  first  day  of 
treatment. 


228  INEBRIETY. 

The  second  day  the  following  is  given.  Each  dose 
contains : 

I£      Strychnine  Nitrate gr.   1-20. 

Atropine  Sulphate gr.   1-200. 

Distilled  Water Vt{  x. 

Mix.  Sig.  Inject  three  times  a  day  for  the  second  day 
of  the  treatment. 

Internally,  patients  are  given  in  connection  with  the 
injections,  the  following,  each  dose  containing: 

I£     Tr.  Cinchona  Comp T)\  xv. 

Tr.  Capsicum 1T\,  ss.  to  j. 

Tr.  Solanum  Carolin Tl\  ij. 

Bitter  Wine  of  Iron q.  s.  ad.  fl.  5  j. 

Mix.    Sig.    One  drachm  three  times  daily. 

Nourishment.  One-half  to  one  glass  of  milk,  (hot  or 
peptonized,)  alternating  with  hot  beef  tea  or  broth,  every 
two  hours. 

Hypnotic.     Used  first  and  second  nights  if  needed. 

I£      Potassium   Bromide    gr.  xxxij. 

Chloral  Hydrate gr.  xvj. 

Tr.  Valerian fl.  5  j- 

Water q.  s.  ad.  fl.  5  iv. 

Mix.  Sig.  Hypnotic.  One  ounce  at  a  dose,  repeated 
as  needed. 

The  stomach  is  washed  out  if  necessary,  to  remedy  any 
catarrhal  disturbance,  and  they  are  given  an  abundance  of 
nourishment.  Two  days  of  this  treatment  usually  finds  them 
with  the  desire  for  liquor  gone,  and  they  are  discharged  with 
the  following-  mixture,  and  directed  to  report  weekly. 


INEBRIETY.  229 

^     Tr.  Columbo A-  o  J • 

Tr.  Capsicum HI  xv. 

Apomorphine    gr.   1-3. 

Tr.  Nux  Vomica fl.  5  j.  to  iss. 

Tr.  Cinchona  Comp q.  s.  ad.  fl.  §  iv- 

Mix.  Sig.  One  drachm  in  water  after  the  three  daily 
meals.  This  is  continued  one  month,  when  he  may  discon- 
tinue taking  this  preparation,  but  he  is  kept  supplied  with 
it,  and  directed  to  begin  taking  it  the  minute  he  feels  a 
desire  for  liquor,  and  report  at  once.  He  is  then  again  given 
the  hypodermatic  injections  as  before. 

By  this  many  persons  are  reclaimed  and  sent  out  with 
confidence  in  themeslves  and  hope  for  the  future,  with  a 
staff  upon  which  to  lean  in  case  of  weakness. 

The  same  treatment  is  also  employed  in  treating  mor- 
phine addiction,  but  in  these  cases  it  must  be  continued 
much  longer  and  sometimes  must  be  modified  by  adding 
bromides  or  gradually  reducing  the  morphine.  The  house 
surgeon  reported  one  case  in  which  the  morphine  was  stopped 
immmediately,  although  thirty  grains  were  taken  daily.  The 
patient  did  not  suffer  in  the  least.  From  an  article  by  Dr. 
C.  L.  Dana,  New  York. — In  the  "Post  Graduate." 


Note : — Having  '  seen  the  same  treatment  outlined  in 
another  medical  journal  in  which  the  dose  of  strychnine  in 
the  first  formula  was  given  as  1-50  grain,  and  the  dose  of 
Tr.  Solanum  in  the  third  formula  as  Tit  xij.,  I  wrote  to  Dr. 
Dana,  and  was  informed  by  him  that  the  formulae  as  I  have 
given  them  here  are  correct.     J.  D.  A. 


230  INEBRIETY. 

A  "Whiskey  Cure  Institute1' 
Treatment. 

The  following  formulae  were  obtained  from  a  physician 
who  was  for  a  number  of  years  connected  with  a  high  priced 
"Institute,"  located  in  New  York. 

On  reception  of  patient,  he  was  given  a  thorough  bath 
and  sweat,  similar  to  the  well  known  Turkish  baths.  This 
was  followed  by  a  thorough  evacuation  of  the  bowels  and 
flushing  of  the  colon  with  three  quarts  of  water  as  warm  as 
could  be  borne.  This  usually  left  the  patient  in  a  relaxed 
condition,  when  the  following  hypodermatic  injection  was 
given : 

I£      Strychnine  Nitrate gr.   1-40. 

Atropine  Sulphate gr.   1-200. 

Aqua  Destil q.  s.  to  dissolve. 

Mix.  Sig.  Give  this  quantity  at  each  injection,  three 
times  a  day  for  four  days,  twice  a  day  for  eight  days  and 
once  a  day  for  four  days. 

Together  with  this,  the  following  pill : 

I£     Quinine  Sulphate gr.  lxxx. 

Zinc  Oxide gr.  lxxx. 

Powd.  Capsicum gr.  lxxx. 

Strychnine  Sulphate gr.     j. 

Acid  Arsenious gr.   1-3. 

Mix.     Ft.  pil  No.  xl. 

Sig.  One  pill,  three  times  a  day,  alternating  with 
hypodermatic  injection.  This  is  given  throughout  the  treat- 
ment. The  pill  is  best  given  half  an  hour  before  the  usuai 
time  for  meals;  the  injections  midway  between  meals  and 
retiring,  while  given  three  times  daily,  midway  between 
meals  when  given  twice,  and  a  few  hours  after  breakfast 
when  given  once. 


INEBRIETY.  231 

If  patient  cannot  sleep  the  following  is  given  : 

1^     Tr.  Aconite  Root n\  v. 

Tr.  Capsicum fl.  5  ss. 

Tr.  Opium  Deodorized, 

Fl.  Ext.  Hyoscyamns. 

Chloral  Hydrate. 

Potassium  Bromide    aa        5  ij. 

Peppermint  Water   q.  s.  ad.  fl.  5  iv. 

Mix.  Sig.  One-fourth  to  one-half  ounce  at  bed-time. 
Use  as  little  as  possible,  and  dilute  freely  with  water. 

If  patient  becomes  much  excited  or  borders  on  delirium 
tremens,  the  following  is  useful : 

IJ     Hyoscine  Hydrobromate gr.   1-200  to  1-100 

Hypodermatically. 
Repeat  pro  re  nata. 
Patients  receive  abundant  nourishment,  soups,  broths, 
beef  tea,  milk,  milk  foods,  peptonized  milk,  and  plenty  of 
water  in  which  sodium  phosphate  has  been  dissolved  in  the 
proportion  of  one  drachm  to  the  pint. 

(Remarks. — As  a  hypnotic,  in  the  treatment  of  inebriety, 
nothing  excels  the  well  known  Bromidia.  Its  action  is 
prompt  and  it  leaves  no  unpleasant  after  effects.     J.  D.  A. ) 


232  INEBRIETY". 


Another   " Institute"    Cure. 

In  the  State  of  Indiana  there  is  in  operation  a  sanitarium 
dedicated  to  the  cure  of  drunkenness  and  nervous  diseases, 
in  which  the  following  line  of  treatment  is  followed : 

After  a  preliminary  treatment  such  as  was  detailed  in 
the  foregoing'  treatment,  the  patient  is  placed  in  a  room  and 
supplied  with  a  bottle  of  good  liquor  with  instructions  to 
help  himself  to  as  much  as  he  wishes.  At  this  time  the 
treatment  is  begun  and  the  patient  receives,  four  times  daily, 
a  hypodermatic  injection  of  the  following  composition: 

I£     Chloride  of  Gold  and  Sodium gr.   1-10. 

Strychnine  Nitrate gr.   1-40. 

Mix. 

In  connection  with  the  above  he  receives  the  following : 

^      Chloride  of  Gold  and  Sodium gr.  xij. 

Ammonium  Muriate gr.  vj. 

Strychnine  Nitrate gr.  j. 

Atropine  Sulphate gr.   1-4. 

Fl.  Ext.  Cinchona  Comp fl.  §  iij. 

Fl.  Ext.  Erythroxylon  Coca fl.  %  j. 

Glycerine fl.  .">  j . 

Distilled  Water fl.  5  j. 

Mix.  Sig.  One  drachm  every  two  hours  while  awake. 
The  physician  in  charge  sees  the  patient  four  times  a 
day  and  increases  the  doses  of  gold  and  strychnine  in  the 
injection  until  the  symptoms  show  that  the  patient  is  receiving 
all  he  can  bear.  The  first  day  the  patient  usually  drinks 
heavily  of  the  whiskey  left  with  him,  but  during  the  second 
day  he  begins  to  lose  his  desire  for  it.  He  will  usually  refuse 
to  take  any  by  the  third  or  fourth  day.  The  treatment  is 
continued  from  three  to  six  weeks,  increasing  or  lessening 
the  doses  according  to  the  symptoms  produced,  always  giving 


INEBRIETY.  233 

the  gold  and  strychnine  to  the  "limit."  The  atropine  causes 
the  pupil  to  be  dilated,  with  some  dimness  of  vision  and  a 
slight  irregularity  of  the  gait  in  walking. 

The  strychnine  causes  a  twitching  of  the  muscles, 
especially  of  the  neck  and  jaws,  and  headache  ensues.  The 
gold  causes  a  red,  irritating  eruption  to  appear  in  the  course 
of  a  week  or  two.  It  appears  all  over  the  body.  Regard 
for  these  symptoms  will  indicate  the  dosage. 

The  theory  of  this  treatment  effecting  cures  is  as  fol- 
lows : 

The  powerful  poisons  given  disturb  the  nerves  so  pro- 
foundly that  the  desire  for  liquor  is  lost  in  the  same  manner 
as  sometimes  occurs  after  a  fit  or  an  attack  of  certain  dis- 
eases. This  breaks  the  tyranny  of  the  habit  and  enables  the 
patient  to  start  on  a  career  of  total  abstinence  without  any 
feeling  of  distress  from  the  lack  of  his  stimulant.  If  he 
begins  tippling,  he  will  soon  acquire  the  taste  and  desire 
again.  The  periodical  drinker  is  said  to  be  the  most  likely 
to  relapse  and  fall  back  into  his  old  habits. 

(Remarks.  The  dose  of  gold  and  sodium  chloride  in 
these  prescriptions  is  undoubtedly  too  large  to  be  safe,  and 
much  larger  than  is  necessary  for  the  production  of  its  physi- 
ological effect.  Doses  of  this  size  would  undoubtedly  in  the 
majority  of  cases,  produce  gastro-enteritis,  vomiting,  digest- 
ive disturbances  and  reduce  the  oxidizing  power  of  the  red 
biood  corpuscles  to  a  point  approximating  if  not  exceeding 
the  danger  point.  The  best  authorities  on  therapeutics  do 
not  advise  its  administration  in  larger  doses  than  1-10  to  1-8 
grain.    J.  D.  A.) 


234  INEBRIETY. 

Dr.  C.  F.  Chapman  of  Chicago,  desirous  of  becoming 
acquainted  with  the  methods  employed  in  Gold  Cure  Insti- 
tutions, obtained  a  position  in  one  of  them  for  this  purpose. 
He  found  that  as  a  "Tonic"  they  used  a  preparation  of  the 
same  composition  as  the  formula  just  given,  with  the  addi- 
tion of  Aloin,  gr.  j,  and  Hydrastin,  gr.  ij.  Dose,  one 
drachm  every  two  hours  from  7  A.  M.  to  9  P.  M.  In  con- 
nection with  this,  the  patient  received  an  injection  contain- 
ing 1-40  gr.  Strychnine  Nitrate  at  8  A.  M.,  12  M.,  4  and  8 
P.  M.  This  quantity  was  gradually  increased  until  strych- 
nine effect  was  very  well  marked.  Combined  with  the 
strychnine  solution,  the  patient  was  given  three  drops  of  the 
following  solution. 

B     Gold  and  Sodium  Chlor gr.  iiss. 

Aqua  Destil   fl.  5  j- 

Mix.  Draw  three  drops  of  this  solution  into  the 
syringe  containing  the  strychnine  solution.  The  mixture 
produces  a  beautiful  golden  color,  to  which  the  attention  of 
the  patient  is  called  for  its  psychic  effect.  It  leaves  a  yellow 
stain  on  the  skin  after  the  needle  has  been  removed.  Dr 
Chapman  has  had  experience  in  300  cases  with  the  treat- 
ment outlined,  with  good  success.  Remarks.  When  such 
large  doses  of  the  Gold  and  Sodium  Chloride  are  success- 
fully administered  by  a  reputable  physician,  it  may  seem 
unwarranted  to  criticise,  yet  Prof.  Waugh  does  not  hesitate 
tc  do  so  in  his  comments  on  the  treatment.  It  may  possibly 
be  that  the  physical  condition  of  a  person  addicted  to  the 
excessive  use  of  stimulants,  counteracts  the  effects  of  the 
gold  salt  to  a  certain  extent,  thus  rendering  the  system 
immune  to  small  doses.  At  any  rate,  the  doses  are  very 
large,  and  if  used,  its  action  should  be  closely  observed. 

Prof.  W.  F.  Waugh,  of  Chicago,  has  also  employed  the 
foregoing  treatment,  in  a  modified  form.  For  the  twelve 
grains  of  Gold  and  Sodium  Chloride,  he  substitutes  one 
grain  of  Bichloride  of  Mercury,  giving  1-48  gr.  of  this  drug 


INEBRIETY.  235 

to  the  dose.  Instead  of  giving  strychnine  hypodermatically 
he  advises  the  use  of  the  alkaloid  caffeine,  dissolved  in  dis- 
tilled water  by  the  addition  of  sodium  salicylate.  This  drug 
greatly  assists  the  solubility  of  caffeine.  From  one  to  six 
grains  are  given  hypodermatically  four  times  a  day.  If  the 
patient's  means  permit  it,  he  uses  mandragorine  instead  of 
atropine,  in  case  the  dose  of  that  drug  is  not  sufficient  in  the 
tonic,  the  former  being  more  efficient  and  less  unpleasant. 
If  in  a  few  days  the  patient's  appetite  for  liquor  does  not 
weaken,  apomorphine  is  added  to  the  liquor  or  given  hypo- 
dermatically, beginning  with  1-30  grain  and  gradually  in- 
creasing it  to  1-10  grain. 

An  important  part  of  his  treatment  now  follows.  For 
the  free  flushing  of  the  emunctories,  the  following  prepara- 
tion is  used. 

E     Potassium  Acetate o  iv. 

Potassium  Bromide gr.  xl. 

Potassium  Nitrate gr.  xv. 

Potassium-  Carbonate gr.  xx. 

Mix.  Dissolve  the  above  in  one  or  two  quarts  of  car- 
bonated water,  (plain  soda  as  dispensed  by  druggists)  and 
let  the  patient  drink  this  quantity  every  day.  The  differ- 
ence in  the  quantity  of  carbonated  water  used  depends  on 
the  capacity  of  the  patient. 

The  diet  should  be  non-stimulating,  plenty  of  fruit 
juices,  vegetable  acids  and  milk,  but  no  rich  foods  or  condi- 
ments. This  treatment  is  continued  until  the  patient  is  well 
and  strong  and  able  to  depend  upon  himself. 


2^6  INEBRIETY. 


Another  Gold  Cure. 

The  following-  treatment  for  inebriety  is  employed  in  a 
certain  institution  near  New  York  City,  under  the  super- 
vision of  a  well  known  physician.  Although  the  "gold 
cures"  were  looked  upon  as  fraudulent  when  they  first 
appeared,  it  is  worthy  of  note  that  the  drug  is  used  and 
relied  upon  in  some  of  our  best  institutions,  and  may  be  said 
to  be  one  of  the  most  important  factors  in  effecting  cures. 

In  detailing  his  method  of  treatment,  the  doctor  as- 
sumes that  the  patient  is  sober  on  his  arrival  at  the  institu- 
tion and  directs  treatment  as  follows. 

Four  times  a  day,  inject  hypodermatically,  a  solution 
containing  1-30  grain  Strychnine  Nitrate  to  ten  minims  of 
distilled  water.  Begin  by  giving  five  minims  and  note 
results.  If  five  do  not  produce  physiological  effects,  gradually 
increase  the  dose  to  ten.  If  the  patient  is  willing  to 
remain  any  length  of  time  necessary  for  a  cure,  not  wishing  a 
"rush  cure"'  this  dose  of  strychnine  nitrate  is  never  exceeded. 
The  first  day  the  patient  receives  about  four  grains  of  calo- 
mel, half  an  hour  after  breakfast,  and  half  an  hour  before 
dinner  a  liberal  dose  of  sulphate  of  magnesia.  If  the  bowels 
do  not  respond  liberally  in  three  or  four  hours,  repeat  the 
salts.  If  the  patient  becomes  irritable,  hankers  after  a  drink 
or  complains  of  a  bad  taste  in  the  mouth,  repeat  the  calomel, 
This  may  be  done  any  time  during  the  treatment. 

Tonic. 

B     Gold  and  Sodium  Chlor gr.  ss. 

Tr.  Gentian fl.  3  x. 

Tr.  Cinchona  Comp fl.  3  iv. 

Tr.  Columbo    fl.  3  iv. 

Tr.  Hydrastis  Canad fl.  3  x. 

Glycerine q.  s.  ad.  fl.  o  ly- 

Mix.     Sig.    One  drachm  four  times  a  day. 


INEBRIETY.  237 

If  the  patient  insists  on  drinking'  after  a  day  or  two, 
give  him  a  small  drink  at  the  usual  time  for  receiving  the 
injections.  After  doing  this  once  or  twice,  add  1-20  to  1-15 
grain  of  apomorphine  to  the  strychnine  solution  and  inject. 
This  usually  has  the  desired  effect.  If  the  patient  is  very 
nervous,  the  following  mixture  is  given. 

3$      Sodium  Bromide   gr.  xv. 

Chloral  Hydrate    gr.  v. 

Tr.  Hyoscyamus    gtt.  xx. 

Elix.  Aromatic q.  s.  ad.  fl.  5  j. 

Aiix.     Sig.    Take  at  a  dose.    Repeat  as  required. 

Occasionally  a  patient  will  be  found  who,  though  com- 
pelled to  vomit  after  an  injection  containing  apomorphine. 
will  persist  in  drinking.  These  cases  are  given  milk  punches 
and  beef  tea,  and  an  injection  containing  in  each  dose. 
Strychnine  Nitrate,  gr.  1-20;  Atropine  Sulphate,  1-100,  and 
Morphine  Sulphate,  gr.  1-4.  This  is  repeated  every  four 
hours  and  the  stomach  soon  rebels,  and  the  trouble  is  over. 
Never  attempt  to  break  off  liquor  too  rapidly,  or  delirium 
tremens  may  ensue,  but  use  judgment  and  be  guided  bv 
the  condition  of  the  patient.  Keep  a  close  watch  over  him 
for  the  first  four  days.  Feed  good,  advise  moderate  exer- 
cise, promote  cheerfulness  and  encourage  the  patient. 


238  INEBRIETY. 


Dr.  Matchette's  Cure  for  Chronic 
Alcoholism. 

The  following  treatment  for  persons  addicted  to  the 
use  of  whiskey  has  been  used  for  more  than  twenty  years 
in  the  institution  of  the  originator  of  the  same,  Dr.  A.  C. 
Matchette,  Bourbon,  Ind.,  according  to  an  article  written 
by  him  and  published  in  a  medical  journal,  several  years  ago. 
So  successfully  has  this  treatment  been  employed  in  the 
various  institutions  under  his  supervision,  that  only  about  2 
per  cent,  of  failures  have  been  recorded,  and  these  have  been 
among  patients  who  refused  to  submit  to  the  full  treatment. 
In  the  experience  of  Dr.  Matchette,  cures  are  more  easily 
effected  when  a  number  of  persons  take  the  treatment  at 
once,  as  it  enables  them  to  find  companions  who  are  in 
sympathy  with  them,  spurs  them  on  to  do  their  best  toward 
assisting  the  treatment  by  creating  a  friendly  rivalry  between 
themselves,  and  prevents  the  solitude  more  or  less  experi- 
enced by  a  single  patient  under  treatment. 

On  entry  of  a  patient  he  receives  a  thorough  hot  bath, 
if  necessary  he  is  given  a  cathartic,  using  the  Comp. 
Cathartic  Pill,  Imp. 

He  is  then  put  on  the  following  injection  : 

J$     Hydrastine  Sulphate gr.     ij. 

Aqua  Destil fl.  %  j. 

Mix.    Filter. 

Sig.  Inject  from  five  to  six  minims  into  the  arm  four 
times  daily,  increasing  the  quantity  to  twenty  or  twenty-five 
minims  within  the  first  fortnight,  if  well  borne,  and  then 
continue  until  cured.  * 

The  first  ten  to  twenty-five  days  he  receives  also,  if 
nervous  and  broken  down,  the  following : 


INEBRIETY.  239 

1^     Fl.  Ext.  Kola. 

Fl.  Ext.  Celery. 

Fl.  Ext.  Valerian. 

Fl.  Ext.  Gentian. 

Fl.  Ext.  Cinchona  Rub. 

Fl.  Ext.  Cannabis  Indica. 

Fl.  Ext.  Erythrox,  Coca. 

Fl.  Ext.  Cypripedium aa  fl.  §  j. 

Mix.     Sig.     One  teaspoonful  every  two  hours. 

If  necessary,  on  account  of  digestive  inactivity,  add  to 
the  above,  Pure  Pepsin,  §  ss.,  and  Hydrastine  Muriate,  3  ss. 

The  above  is  alternated  with  the  following  for  four  or 
five  days,  then  the  time  between  the  doses  of  the  following 
are  lengthened  as  found  best. 

1$     Hydrarg,  Bichlorid gr.  iv. 

Sodium  Bromide   5  ij. 

Potassium  Bromide ^  iss. 

Potassium    Iodide 5  iij. 

Ammonium  Chloride 3  iij. 

Water Oj. 

Mix.  Sig.  One-half  teaspoonful  every  two  hours, 
taken  in  a  strong  decoction  of  coca  leaves. 

Treatment  is  to  be  continued  until  the  patient  is  dis- 
charged cured,  usually  in  about  three  weeks.  During  the 
first  12  to  72  hours  the  patient  is  furnished  with  a  generous 
quantity  of  the  best  liquor,  until  he  declines  to  use  it,  which 
is  often  within  the  first  day.  Some  will  be  determined  to 
continue  the  use  of  liquor,  and  boast  of  such  determination, 
but  they  are  usually  the  first  to  refuse  it.  Others  will  say 
little  but  will  tenaciously  cling  to  their  flask,  making  one 
effort  after  another  to  retain  a  drink,  until  finally,  sometimes 
after  vomiting  twenty  times  or  more,  they  come  to  the  con- 
clusion that  they  have  enough. 


24O  INEBRIETY. 

The  treatment  must  not  be  discontinued  when  the 
patient  refuses  liquor,  even  if  the  taste  or  smell  of  it  causes 
vomiting,  but  it  must  be  continued  until  the  physician  has 
determined  that  the  cure  is  complete.  Vast  differences  exist 
in  patients  and  each  case  must  be  treated  according  to  the 
particular  demands  thereof,  varying  the  remedies  employed 
as  indicated.  These  variations  cannot  be  defined  or  fully 
described,  but  tbe  physician  treating  a  number  of  patients 
will  observe  them,  and  experience  will  improve  and  mature 
his  judgment.  The  variations  found  will  usually  depend 
on  age,  weight,  physical  condition  and  ability  to  bear  the 
treatment  either  lighter  or  heavier,  as  the  case  may  be. 
Good  nourishment  is  necessary,  using  cereals,  prepared  foods, 
milk,  etc.  Cheerful  associations  are  highly  beneficial  and 
should  be  encouraged  as  much  as  possible. 

(Remarks. — In  the  hypodermatic  injection  given,  instead 
of  increasing  the  dose  to  20  or  25  minims,  I  would  suggest 
that  stronger  solutions  of  the  drug  be  procured.  An  injec- 
tion of  25  minims  is  quite  bulky.  The  dose  of  Cannabis 
Indica  is  rather  large,  in  the  second  prescription,  and  as  this 
is  a  dangerous  drug  its  action  should  be  watched,  and  modi- 
fied accordingly.     T.  D.  A.) 


ACUTE   ALCOHOLISM.  24.I 

Treatment  for  Acute  Alcoholism. 

It  is  frequently  very  important  that  a  person  under  the 
influence  of  alcoholics  should  become  sober  as  soon  as  pos- 
sible. Business  affairs  may  be  neglected  or  social  engage- 
ments forgotten  during  the  period  of  indulgence,  and  it  often 
devolves  upon  friends  of  the  habitual  drunkard  to  assist 
him  to  the  possession  of  an  unclouded  brain  and  clear  intel- 
lect, and  see  to  it  that  his  appearance  at  least  is  respectable. 

If  he  has  recently  drank  intoxicants,  the  first  indication 
is  an  emetic.  This  may  be  accomplished  by  drinking  freely 
of  warm  water,  tickling  the  fauces  with  a  feather  or  intro- 
ducing the  forefinger  as  far  down  the  throat  as  possible. 
Should  these  measures  fail,  sulphate  of  zinc,  twenty  grains 
dissolved  in  half  a  glass  of  warm  water,  should  be  given. 
If  this  is  not  at  hand  a  teaspoonful  of  mustard  will  prove 
an  excellent  substitute.  Tartar  emetic  by  the  mouth  or 
apomorphine  hypodermatically  may  have  to  be  used  if  all 
else  fails.  After  free  emesis,  the  vegetable  acids,  especially 
lemon  juice,  will  prove  grateful  and  beneficial. 

If  he  has  not  drank  recently  and  the  liquor  has  circu- 
lated through  his  system,  emetics  are  of  no  value.  Here 
the  Muriate  of  Ammonia,  20  to  30  grains,  dissolved  in  half 
a  glass  of  water,  will  give  splendid  results,  as  will  also  ounce 
doses  of  freshly  prepared  Liq.  Ammon.  Acetate.  Either  of 
these  remedies  may  be  repeated  in  half  an  hour  or  less. 

As  the  emetics  will  only  relieve  the  stomach  of  its  con- 
tents, and  as  the  intoxicated  person  is  always  under  the 
influence  of  alcoholics  which  have  been  absorbed,  the  prepara- 
tions of  ammonia  just  mentioned  should  be  administered 
after  the  stomach  has  been  emptied. 

Another  method  by  which  the  effects  of  alcoholics  can 
quickly  be  dispelled  is  the  hypodermatic  injection  of  1-3  to 
1-2  gr.  Morphine  Sulph.  It  may  be  combined  with  1-15 
or  even  1-8  of  Strychnine  Nitrate.  After  a  short  nap,  the 
person  can  be  awakened  with  his  senses  comparatively  nor- 
mal. A  thorough  sweating  will  facilitate  matters  consid- 
erably. 


2^2.  TOBACCO   ADDICTION. 


TOBACCO    ADDICTION. 

As  in  other  addictions,  the  person  desiring  to  free  him- 
self from  the  use  of  tobacco  must  exercise  his  will  power  to 
the  full  extent. 

No  remedy  will  cure  any  one  so  thoroughly  that  the 
habit  may  not  again  be  easily  acquired,  although  if  ordinary 
efforts  are  made  to  avoid  tobacco  for  several  months,  it  will 
be  comparatively  easy  to  let  it  alone  thereafter. 

On  account  of  the  numerous  remedies  advertised  to  the 
laity  by  different  firms,  there  is  a  certain,  although  limited, 
demand  made  upon  physicians  for  medicine  of  this  character. 
The  following  formula  is  a  good  one,  and  if  left  to  the 
patient  entirely,  if  he  makes  an  effort  to  use  it  regularly  and 
does  not  force  tobacco  on  himself,  will  cure  seventy-five  per 
cent,  of  cases.  To  those  who  require  additional  treatment, 
add  sufficient  Tartar  Emetic  to  the  remedy,  or  give  it  sepa- 
rately, to  sicken  them.    Formula : 

R      Atropine  Sulphate gr.   1-8. 

Tr.  Quassia, 

Tr.    Columbo aa  fl.  5   '}• 

Tr.  Humulus. 

Sp.  Vini  Rect aa  fl.  5  ss. 

Aqua q.  s.  ad.  fl.  §  iv. 

Mix.    Sig.    Teaspoon ful  every  three  hours  while  awake. 

If  for  chewing,  let  the  patient  have  fine  cut  (no  plug) 
two  or  three  times  a  day  for  a  few  days.  The  atropia  causes 
dryness  of  the  mouth  and  fine  cut  usually  disgusts  them.  If 
not,  use  the  Tartar  Emetic. 

If  for  smoking,  allow  a  short  smoke  several  times  daily, 
not  more  than  one- fourth  of  a  cigar,  to  be  re-lit  when  another 
smoke  is  taken.  If  a  cigar  smoker,  give  him  a  strong  pipe; 
this  will  not  be  as  pleasant  as  a  cigar.  After  a  few  days 
stop  smoking  altogether,  but  if  there  is  difficulty  in  stopping, 
use  the  emetic  as  directed. 


TOBACCO    ADDICTION.  243 

The  following  is  the  formula  of  a  well  known  proprie- 
tary remedy  in  tablet  form,  which  is  recommended  for  both 
Alcohol  and  Tobacco.     Formula  : 

I>      Gold  and  Sodium  Chlor gr.  j. 

Strychnine  Nitrate gr.   1-3. 

Nitro   Glycerine    gr.   1-10. 

Quassin gr.  iss. 

Atropine,   alk o-r.   1-10. 

Oleores  Capsicum   gr.  vj. 

Tr.  Digitalis gtt.  xl. 

Mix  with  any  suitable  excipient  and  make  Twenty  pills 
or  tablets.     Sig.     One  tablet  or  pill  before  each  meal. 

The  above  directions  regarding  the  use  of  tobacco  apply 
to  this  treatment. 

Another  formula,  somewhat  similar  to  the  above. 
Iy      Gold  and  Sodium  Chlor gr.  iv. 

Strychnine  Nitrate    gr.  ij. 

Nitro  Glycerine gr.  ss. 

Ext.  Digitalis  fid Tt\  xx. 

P'ulv.  Capsicum gr.  xxv. 

Salicin o-r    r 

Cinchonidin.  Sulph gr.  c. 

M.  Ft.  Pil  No.  100. 
Sig.    One  before  meals. 

Continue  using  tobacco  in  somewhat  reduced  quantity 
for  a  few  days,  then  make  an  effort  to  stop  it.  Continue 
treatment  until  free  from  the  desire  for  tobacco. 

Another  formula  for  Tobacco  Addiction  : 

PJ     Apomorphine  Muriate   gr.  iv. 

Ac.  Muriatic  Dil fl.  3  ij. 

Tr.  Nux  Vomica fl.  %  ss. 

Aqua  Dest q.  s.  ad.  fl.  %  viij. 

Mix.  Sig.  One  half  to  one  teaspoonfnl  every  two 
hours. 


244  GOITRE. 


GOITRE. 


A  thoroughly  reliable  treatment  for  this  obstinate  affec- 
tion will  undoubtedly  be  appreciated  by  the  majority  of 
physicians.  The  following  formulae,  if  properly  and  persis- 
tently used,  will  cure  all  ordinary  cases  of  goitre  and  benefit 
all  others.  I  have  used  this  treatment  in  numerous  cases 
with  entire  satisfaction,  effecting  cures  which  have  remained 
permanent  for  several  years. 
Injection  Fluid  No.   I. 

R      Pure   Carbolic    Acid fl.  5  ss. 

Aqua  Destil fl.  5  j. 

Ft.  Solution  and  add 

Pure  Glycerine fl.  5  ss. 

Shake  well  and  add 

Tr.  Iodine fl.  •"  ij. 

Mix. 

Injection  Fluid  No.  2. 

IJ      Iodoform     gr.   xl. 

Pure   Glycerine    fl.  5  iij. 

Mix  thoroughly  in  a  glass  mortar  and  pour  into  a 
colored  bottle. 

Local  Application. 

Ik      Tartar  Emetic 5  ss. 

Aqua  Destil fl.  %  ss. 

Ft.  Solution  and  add 

Tr.    Iodine    fl.  %  iij. 

Tr.   Benzoin  Comp fl.  o  ij. 

Mix. 

For  treating  all  varieties  of  goitre  except  cystic,  vas- 
cular and  exopthalmic.  With  a  hypodermatic  syringe  inject 
one  to  five  minims  of  injection  fluid  No.  1  into  the  substance 
of  the  goitre  once  each  week.  With  the  same  instrument 
inject  from  two  to  ten  minims  of  injection  fluid  No.  2  into 


GOITRE.  245 

the  substance  of  the  goitre  once  each  week.  Commence 
with  fluid  No.  2  three  days  after  commencing  with  fluid  No. 
i,  and  alternate  with  them,  not  using  one  of  them  in  less 
than  three  days  after  using  the  other.  It  is  not  necessary 
to  plunge  the  needle  deep  into  the  enlarged  gland,  but  be 
sure  it  has  entered  before  injecting.  Insert  the  needle, 
instruct  the  patient  to  swallow ;  if  properly  introduced  the 
needle  will  follow  the  goitre  in  its  upward  movement.  If  the 
patient  is  under  twenty  years  of  age,  one  to  four  minims 
(according  to  age),  of  No.  1  will  be  sufficient.  Where  the 
patient  is  older,  and  especially  if  of  long  standing,  it  will  in 
some  cases  be  necessary  to  use  the  maximum  dose  of  both 
fluids.  If  the  goitre  is  bilateral  inject  one  side  at  one  time 
and  the  other  side  at  the  next  time,  alternating  in  this  man- 
ner until  cured. 

The  local  application  is  used  at  the  same  time.  Instruct 
the  patient  to  paint  the  skin  covering  the  goitre  twice  a  day 
until  considerable  vesication  is  produced,  then  once  a  day  or 
as  necessary  to  keep  up  considerable  irritation. 

CYSTIC  GOITRE. 

Evacuate  the  contents  of  the  cyst  with  the  hypodermatic 
syringe,  and  then  inject  into  the  cavity  about  five  to  eight 
minims  of  injection  fluid  No.  1,  and  allow  it  to  remain. 
Repeat  twice  a  week  until  cured. 

These  cases  usually  get  well  in  from  two  to  six  weeks. 
Use  the  local  application  same  as  in  the  other  varieties. 

VASCULAR  GOITRE. 

In  treating  this  form  of  the  disease  use  the  local  appli- 
cation same  as  in  the  other  varieties.  Every  eight  days  inject 
from  two  to  five  minims  of  injection  No.  2  into  the  substance 
of  the  goitre,  and  every  eight  days  inject  from  one  to  five 
minims  of  injection  No.  1  into  the  tissues  just  beneath  the 
skin  covering  the  goitre,  and  not  into  the  substance  of  the 
gland  as  in  other  varieties.  Make  an  injection  every  four 
days,  alternating  with  the  two  fluids. 


246  GOITRE. 

Remarks : — In  preparing  the  formulae  add  the  different 
ingredients  in  the  order  named,  and  in  preparing  No.  1  add 
the  iodine  slowly,  shaking  constantly.  In  using  injection 
No.  2  pour  into  a  small  bottle  the  desired  amount  and  add 
an  equal  quantity  of  pure  water  and  shake  well  before  filling 
the  syringe.  This  is  done  to  dilute  it  so  it  will  pass  through 
the  needle.  If  you  use  a  larger  needle  this  will  not  be 
necessary.  These  injections  should  be  prepared  freshly  as 
often  as  ever}-  four  weeks.  Keep  the  needle  clean,  smooth, 
sharp  and  free  from  rust.  Always  see  that  the  air  is  out  of 
the  syringe  before  injecting.  In  case  there  is  no  improve- 
ment in  four  weeks,  don't  become  discouraged  and  quit,  as 
the  enlargement  may  disappear  very  rapidly  after  it  begins 
to  be  reduced.  The  average  time  required  varies  from  eight 
to  twelve  weeks.  Don't  imagine  that  because  the  treatment 
is  simple,  that  it  is  without  merit,  but  give  it  a  fair  trial,  and 
you  will  be  more  than  pleased. 


Other  Remedies  for  Goitre. 

The  Chloride  of  Ammonium  Treatment.  This 
method  of  treatment  was  first  suggested  on  account  of  the 
well  known  absorptive  action  of  the  Chloride  of  Ammonium, 
when  used  in  the  treatment  of  enlarged  glands,  either  parotid 
or  lymphatic ;  the  local  action  of  the  Red  Iodide  of  Mercury 
being  no  doubt  largely  contributory  to  the  good  results  often 
obtained.    The  directions  for  treatment  are  as  follows  : 

The  Chloride  of  Ammonium  should  be  given  in  eight 
or  ten  grain  doses,  three  times  daily,  and  continued  for  weeks 
o,r  months.  Locally  use  an  ointment  containing  Red  Iodide 
of  Mercury,  grs.  x  to  xx  to  the  ounce  of  Vaseline,  rubbed 
well  over  the  whole  surface  of  the  goitre  once  a  day  until 
slight  vesication  appears.  Discontinue  then  and  repeat  when 
the  vesication  produced  by  the  former  application  has  disap- 
peared. This  may  require  two  or  three  weeks.  It  should  be 
noted  that  this  ointment  should  not  be  applied  to  the  vesicated 


GOITRE.  24/ 

surface,  or  where  any  abrasion  of  the  skin  exists,  on  account 
of  its  powerful  action  constitutionally.  As  an  alternating 
remedy  the  Iodide  of  Potassium  in  five  grain  doses,  three 
times  a  day,  may  be  given  one  week  out  of  every  four.  Con- 
tinue in  this  manner  until  satisfactory  results  are  obtained. 

Dr.  Chavette's  Goitre  Remedy. 
The  following  prescription  was  used  for  many  years  by 
Dr.  Chavette,  of  Chicago,  with  such  success  that  he  gained 
both  fame  and  fortune. 
1$     Zinc  Sulphate, 

Acid  Salicylic aa  0  ij. 

Iodoform, 

Acid  Boracic aa  5  iij. 

Acid  Oleic o  viij. 

Mix  and  keep  at  boiling  heat  for  four  hours,  then  pour 
off  the  liquid  and  after  cooling,  bottle  and  cork  well. 

Sig.  Apply  to  the  enlarged  gland  with  slight  friction, 
twice  daily  until  slight  desquamation  occurs,  after  which 
apply  once  daily  until  the  enlargement  is  entirely  reduced. 
Cures  effected  by  this  method  are  said  to  be  permanent. 

Fucus  Vesiculosus.  This  is  a  remedy  that  has  at  vari- 
ous times  been  brought  forward  as  a  remedy  for  Goitre, 
indeed  Dr.  R.  N.  Foster,  of  Chicago,  claims  it  to  be  the  only 
remedy  that  he  has  ever  known  to  cure  Goitre.  The  drug 
is  very  likely  to  deteriorate,  and  many  preparations'  of  it 
are  unreliable.  The  dose  varies  according  to  the  prepara- 
tion used  and  should  be  taken  according  to  dosage  given  for 
the  particular  preparation  employed.  It  should  only  be  pur- 
chased from  the  most  reliable  parties. 


Electric  Treatment.  The  treatment  of  Goitre  by 
cataphoresis  is  a  safe  and  very  often  effectual  means  by 
which  goitre  can  be  cured.  A  strong  solution  of  potassium 
iodide  is  applied  to  the  tumor  on  a  well  wetted  pad,  attached 
to  the  cathode  of  a  galvanic  battery.    The  positive  pole  may 


248  GOITRE. 

be  placed  at  the  back  of  the  neck  or  other  convenient  locality. 
The  opposite  side  of  the  tumor  is  a  good  location  for  the 
positive  pole.  A  current,  from  five  to  fifteen  milliamperes, 
is  to  be  used.  The  treatment  should  be  given  every  other 
day,  unless  the  parts  become  too  tender,  and  should  con- 
tinue about  fifteen  minutes  at  a  time. 

The  action  of  the  electric  current  is  to  liberate  the  iodine 
from  the  iodide  of  potassium,  and  the  iodine  being  an  electro 
negative  body  is  repelled  from  the  cathode  or  negative  pole, 
as  like  poles  repel  and  unlike  poles  attract.  The  potassium, 
being  electro  positive,  remains  on  the  negative  electrode  while 
the  iodine  is  passed  toward  the  positive  electrode,  and  if  the 
action  were  continued  long  enough  the  free  iodine  would  be 
found  on  the  positive  electrode.  Proof  that  it  is  absorbed 
can  also  be  shown  by  simply  reversing  the  electrodes.  Free 
iodine  will  at  once  appear  under  the  positive  electrode  where 
the  negative  formerly  was  applied,  and  on  reversing  again  to 
the  first  position  the  iodine  at  once  disappears.  Change  of 
current  will  produce  the  same  effect  without  removing  the 
electrodes. 

This  treatment  causes  no  discoloration  of  the  skin  other 
than  the  hyperaemia  produced  by  the  current.  This  treat- 
ment should  be  continued  until  the  growth  of  the  gland  is 
sufficiently  reduced.  The  improvement  is  not  rapid  but 
will  in  many  cases  prove  satisfactory.  Persons  with  goitre 
are  usually  acquainted  with  the  usually  accepted  theory  that 
goitre  is  incurable,  and  any  means  that  shows  a  reduction 
will  in  the  majority  of  cases  be  willingly  continued.  Diminu- 
tion in  size  is  usually  first  noticed  by  the  patient  on  account 
of  the  collar  worn,  and  the  measurement  sometimes  recom- 
mended is  entirely  unnecessary.  The  patient  will  notice  a 
reduction  before  the  tape  line  would  indicate  it. 


NASAL    CATARRH.  249 


NASAL  CATARRH 


Acute  and  Chronic. 


There  is  no  dearth  of  literature  on  Catarrh.  Medical 
text  books  and  the  periodical  publications  which  give  space 
to  the  consideration  of  this  disease  are  abundant  evidence 
that  the  authors  of  the  former  and  editors  of  the  latter  are  in 
a  measure  endeavoring  to  cater  to  the  evident  demand  for 
information  on  the  subject. 

To  any  careful  observer,  and  all  physicians  should  be 
such,  it  must  be  apparent  that  catarrhal  diseases  of  the 
Nose  and  Throat,  with  their  consequences,  complications 
and  reflex  disturbances  are  responsible  for  many  of  the  ills 
that  flesh  is  heir  to,  and  that  the  intelligent  treatment  of 
them  becomes  an  absolute  necessity  to  any  physician  who 
assumes  the  responsibility  of  accepting  a  case  for  treatment. 
The  large  and  remunerative  practice  so  generally  enjoyed 
by  physicians  who  give  special  attention  to  the  diseases  of 
the  Nose  and  Throat  is  evidence  sufficient  that  this  class  of 
affections  can  be  made  to  play  a  most  important  part  in  the 
practice  of  every  physician  who  gives  them  somewhat  more 
ihan  passing  attention. 

Probably  no  part  of  the  human  body  has  been  so  abused 
and  maltreated  as  the  upper  air  passages.  Every  malodor- 
ous irritant,  sold  under  the  guise  of  an  antiseptic  powdet, 
has  been  blown,  syringed,  douched  and  sprayed  into  these 
cavities,  until  physicians  have  become  discouraged  and  do 
not  hesitate  to  assert  that  Catarrh  cannot  be  cured. 


25O  NASAL    CATARRH. 

There  seems  to  be  a  prevailing  opinion  in  the  minds  of 
many  of  the  profession  that  the  correct  treatment  of  these 
diseases  implies  the  use  of  certain  expensive  and  elaborate 
apparatus,  and  the  possession  of  more  than  an  ordhmry 
degree  of  skill  to  use  them  properly,  so  that  the  outcome  in 
many  instances  has  been  that  the  general  practitioner  has 
allowed  his  cases  to  drift  to  the  specialist,  if  indeed  he  has 
not  had  the  magnanimity  to  direct  them  there. 

By  a  moderate  amount  of  study  and  diligent  practice, 
by  perserverance  in  the  use  of  the  methods  at  hand,  the  gen- 
eral practitioner  may  overcome  many  imaginary  difficulties 
that  seem  to  stand  between  him  and  success,  and  he  will  be 
richly  rewarded  for  his  time  and  labor  so  spent. 

The  instruments  that  we  may  class  under  the  list  of 
those  strictly  necessary  are:  a  good  lamp  with  reflector  or  a 
condenser,  a  head  mirror,  a  nasal  speculum,  a  tongue  depres- 
sor and  a  laryngeal  mirror.  As  time  passes  and  the  practi- 
tioner becomes  more  skillful  in  their  use  and  more  bold  in  his 
undertakings,  other  more  elaborate  instruments  may  be 
added,  but  of  these  we  will  speak  later  on. 

Acute  Rhinitis. 
(Cold  in  the  Head.) 

This  condition  is  so  common  as  to  almost  warrant  an 
omission  of  the  symptoms  here,  but  we  will  mention  them  in 
passing.  Frontal  headache,  general  malaise,  nose  discharg- 
ing a  thin  and  irritating  secretion  which  is  responsible  for 
the  excoriation  that  you  will  observe  on  the  upper  lip  and 
lower  part  of  the  nose.  Breathing  through  the  nose  is  im- 
possible and  much  of  the  general  indisposition  is  due  to  this 
fact ;  it  prevents  restful  sleep.  The  throat  feels  parched  and 
irritated  and  the  tongue  is  usually  heavily  coated,  due  mostly 
to  the  mouth  breathing. 

A  saline  laxative  will  usually  somewhat  improve  the 
general  feeling,  while,  internally  a  tablet  containing  the  fol- 
lowing, will  to  some  extent  control  the  local  symptoms. 


NASAL    CATARRH.  25 1 

iy     Quinine  Sulph gr.  ss. 

Ext.  Belladonna  lvs gr.  1-8. 

Camphor  Monobrom gr.  j. 

Caffeine  Citrat gr.  ss. 

M.     Ft.  tablet  or  capsule  No.  j . 

Sig.  One  every  two  or  three  hours  according  to  require- 
ments. 

For  speedy  relief,  local  treatment  is  undoubtedly  greatly 
superior  to  internal  medication,  but  both  can  be  used  to 
advantage. 

On  inspection  the  interior  of  the  nose  will  be  found  to 
be  congested  and  swollen  and  a  simple  method  of  relieving 
this  congestion  at  once  suggests  itself — the  use  of  cocaine. 
For  this  purpose  a  two  per  cent,  or  four  per  cent,  solution  is 
used.  A  pledget  of  cotton  about  the  size  of  the  nostril  is 
saturated  with  the  solution  and  placed  within  the  nose  and 
well  up  to,  and  pressing  against  the  turbinates,  and  allowed 
to  remain  there  for  a  period  of  ten  minutes.  When  it  is 
removed,  the  mucous  membrane  which  ten  minutes  before, 
was  so  red  and  angry  looking,  will  now  be  seen  to  be  dry, 
pale  and  shrunken  and  your  patient  will  be  able  to  breathe 
through  the  nose.  The  effects  of  cocaine  will  usually  dis- 
appear in  about  thirty  minutes,  when  the  symptoms  will 
again  return.  In  order  to  prolong  the  effect  of  the  cocaine, 
the  interior  of  the  nose  should  be  sprayed  with  a  four  per 
cent,  solution  of  antipyrine,  which  will  maintain  the  cocaine 
effect  for  a  period  of  five  to  eight  hours,  and  will  be  fol- 
lowed by  no  reaction,  but  rather  a  decided  improvement. 

The  temporary  smarting  which  is  produced  by  the  four 
per  cent,  solution  of  antipyrine,  will  pass  away  very  quickly, 
but  antipyrine  should  never  be  used  in  as  strong  as  four  per 
cent,  solution  without  the  previous  application  of  cocaine. 

In  the  pharynx  and  larynx,  much  stronger  solutions  of 
antipyrine  may  be  used  without  discomfort. 


252  NASAL    CATARRH. 

Never  apply  cocaine  solution  inside  the  nose  with  an 
atomizer,  as  in  that  case  there  is  always  danger  of  the  patient 
swallowing  an  unknown  quantity  as  almost  invariably  a  por- 
tion of  the  fluid  reaches  the  pharynx.  Again,  cocaine  applied 
to  the  pharynx  nearly  always  causes  a  feeling  of  dryness 
and  the  presence  of  a  foreign  body,  and  may  even  cause 
nausea  and  vomiting  in  extremely  susceptible  persons.  Ni- 
trate of  silver  has  much  the  same  effect  and  it  may  be  said 
to  be  a  general  rule  never  to  use  cocaine  or  nitrate  of  silver 
in  the  pharynx,  except  in  atrophic  pharyngitis ;  in  which  the 
latter  is  of  value. 

A  patient  under  treatment  by  the  cocaine  and  antipyrine 
solutions,  should  be  instructed  to  present  himself  in  about 
six  hours.  Antipyrine  may  now  be  applied  in  a  one  per  cent. 
or  two  per  cent,  solution  and  should  be  followed  by  a 
thorough  spraying  of  a  solution  of  aromatic  antiseptics  pro- 
tected by  an  oily  substance,  as  the  following : 

I£      Menthol   gr.  x. 

Ol.  Eucalyptol   nx  vj. 

Camphorated  Alboline,  3  to  5  % .  .  .   fl.  §  iv. 
M.     Sig.     Spray  into  nose  three  or  four  times  a  day. 

For  the  excoriated  spots  inside  the  nose,  as  well  as  those 
on  the  external  parts,  calomel,  thinly  dusted  over  them,  will 
hasten  their  repair  as  well  as  afford  immediate  relief. 

This  treatment  will  usually  conquer  an  acute  attack  of 
this  sort  in  twenty-four  to  thirty-six  hours.  Should  the 
conditions  demand  it,  the  cocaine  on  cotton  applications  may 
be  repeated  once  or  twice  before  the  spray  is  given.  Should 
the  circumstances  of  the  patient  be  such  as  to  render  it 
impossible  for  him  to  call  at  the  office  for  frequent  repeti- 
tions of  the  treatment,  an  oil  atomizer  with  sufficient  solu- 
tion may  be  given  him  with  directions  for  use,  together  with 
the  following  powder  which  is  to  be  used  as  a  snuff  suffi- 
ciently often  to  secure  relief  from  excessive  secretion  and 
nasal  stenosis. 


NASAL    CATARRH.  253 

K      Menthol grs.  ij. 

Magnesia  Carbonate,   light grs.  x. 

Cocaine  Muriate grs.  viij. 

Saccharnm  Lact •>  uj- 

M.     Make  an  impalpable  powder. 
Sig.     Use  as  a  snuff  as  directed. 

By  the  use  of  this  preparation  nasal  stenosis  may  be 
relieved  for  an  indefinite  time,  and  therein  lies  the  danger 
that  it  may  lead  to  the  formation  of  cocaine  addiction.  A 
moderate  use  of  cocaine  for  a  short  time  is  never  dangerous 
in  this  particular,  but  in  order  to  prevent  the  patient  from 
using  the  above  powder  after  the  acute  symptoms  have  sub- 
sided, supplv  the  powder  yourself  in  small  quantities  only, 
and  never  tell  the  patient  that  he  is  using  cocaine.  Tn  this 
manner  you  have  complete  control  of  the  supply  and  can 
use  proper  precautions. 

Chronic   Nasal  Catarrh. 

For  the  purpose  of  considering  this  disease  in  as  plain 
and  easily  understood  a  manner  as  possible,  we  will  make  the 
following  divisions : 

Simple  Chronic  Rhinitis,  Hypertrophic  Rhinitis,  Atro- 
phic Rhinitis. 

Simple  Chronic  Rhinitis. 

This  condition  may  be  said  to  be  present  when  there  is 
a  chronic  inflammatory  congestion  of  the  nasal  mucous 
membrane,  with  but  few  if  any,  structural  changes.  It  is 
usually  due  to  recurrent  attacks  of  acute  rhinitis  which  may 
be  due  to  the  habits  of  the  individual  or  constitutional 
disease.  Bathing  in  cold  water,  sleeping  in  rooms  with  too 
much  ventilation,  inhalation  of  dust  or  irritating  substances 
are  a  frequent  cause  of  this  condition,  as  well  as  are  dis- 
eases of  the  stomach  and  constipation. 


254  NASAL    CATARRH. 

The  chief  and  only  symptom  of  Simple  Chronic 
Rhinitis  is  a  profuse  secretion  of  mucus,  or  sometimes  when 
of  long  standing,  muco-pus. 

Examination  will  reveal  a  nasal  membrane  more  or  less 
congested,  with  here  and  there  spots  of  yellowish  or  whitish 
mucus.  The  epithelium  may  be  abraided  in  spots  or  some- 
times extensively,  due  perhaps  as  much  to  the  frequent 
attempts  at  relieving  the  nose  of  the  accumulation  of  mucus 
as  to  the  disease  itself.  In  the  vault  of  the  pharynx  and 
posterior  nares  where  there  is  more  glandular  tissue,  there 
will  be  more  swelling  than  anteriorly,  and  the  secretions  will 
be  found  to  be  more  tenacious. 

Treatment: — The  nose  should  be  cleansed  of  the  dry 
secretions  by  the  use  of  an  alkaline  wash  which  may  be  used 
twice  a  day.  The  well  known  Dobell's  solution  may  be 
used  for  this  purpose  or  if  the  patient  dislikes  the  carbolic 
acid  odor,  other  alkaline  and  antiseptic  agents  may  be 
employed.  These  are  furnished  by  all  pharmaceutical 
houses  in  tablet  form.  It  should  be  borne  in  mind,  however, 
that  carbolic  acid  has  not  only  an  antiseptic  action  in  the 
Dobell's  solution,  but  that  it  is  decidedly  sedative  in  its 
action.  On  this  account,  unless  the  odor  of  the  acid  is  decid- 
edly obnoxious  to  the  patient,  this  solution  is  to  be  preferred 
to  many  others  which  though  more  elegant,  are  vastly 
inferior  to  this  old  and  valuable  remedy.  The  formula  of 
Dobell's  solution,  although  familiar  to  most  physicians,  will 
here  be  given. 

I£      Sodium  Bicarb. 

Sodium  Biborat  aa  5  j. 

Acid  Carbolic 5  ss. 

Glycerine    fl.  5  j- 

Aqua q.  s.  ad.  Oij. 

Mix. 

The  alkalies  render  the  mucous  secretions  more  fluid, 
the  carbolic  acid  acts  both  as  an  antiseptic  and  a  sedative, 
while  the  glycerine  is  added  to  increase  the  specific  gravity 


NASAL    CATARRH.  255 

to  nearer  that  of  the  normal  secretions.  No  matter  what 
the  composition  of  a.  nasal  douche  may  be,  it  will  be  irritat- 
ing if  the  specific  gravity  is  much  more  or  much  less  than 
that  of  blood  serum.  It  is  well  therefore  to  bear  in  mind 
that  when  tablets  are  used  to  form  solutions  for  douching  the 
nose,  glycerine  to  the  amount  of  an  ounce  to  the  quart  should 
be  added.  Dobell's  solution  should  not  be  used  freshly 
prepared,  but  should  be  allowed  to  stand  for  a  week  or  ten 
days  and  filtered.  It  is  then  that  its  bland  and  sedative 
action  is  most  marked. 

The  best  method  of  using  solutions  of  this  kind  is  by 
means  of  an  atomizer.  Direct  the  patient  to  point  the  noz- 
zle slightly  downward  while  using,  as  to  point  it  upward  as 
the  majority  will  do  unless  properly  instructed,  will  often 
cause  severe  pain  in  the  ethmoidal  sinuses.  Direct  the 
patient  to  insert  the  nozzle  fully  one-half  inch  and  to  point 
it  toward  the  lower  part  of  the  ear.  The  head  should  be 
tilted  slightly  backward  when  using  the  atomizer.  The  soft 
rubber  ear  syringe  may  be  used  for  the  purpose  of  cleansing 
the  nasal  passages,  but  as  these  are  usually  found  with  a  tip 
more  than  two  inches  long,  it  is  well  to  cut  them  down  to 
about  an  inch.  By  this  method  more  solution  is  wasted  than 
by  the  use  of  the  atomizer  and  the  results  are  not  as  satisfac- 
tory, but  under  certain  circumstances  their  use  is  justified, 
notably  among  those  whose  nasal  membrane  is  so  sensitive 
as  to  cause  excessive  sneezing  or  nausea.  The  douche  or 
spray  should  be  used  twice  or  three  times  daily. 

Locally,  the  use  of  the  Iodine-Glycerine  solution  should 
be  applied  two  or  three  times  a  week.  The  application 
should  be  made  to  the  floor  of  the  nose  and  the  naso-pharynx 
or  to  all  the  affected  parts.     The  formula  for  this  solution  is  : 

5      Iodine  resub grs.  x. 

Potassium  Iodide grs.  xxx. 

Glycerine    fl.  %  ij. 

Mix. 


256  NASAL    CATARRH. 

In  preparing  this  solution  the  Iodide  of  Potassium  and 
the  Iodine  should  be  rubbed  together  in  a  mortar  and  the 
glycerine  added  slowly.  After  an  application  of  this  solu- 
tion the  Menthol-Alboline  spray,  formula  of  which  is  given 
under  Acute  Rhinitis  may  be  used.  It  acts  as  a  protective 
and  prevents  too  rapid  evaporation  of  the  iodine. 

The  discharge  of  mucus  is  usually  thinner  and  more 
watery  after  an  application  of  the  Iodine-Glycerine  solu- 
tion and  the  patient  should  be  instructed  not  to  blow  the 
mucus  out  through  the  nose,  but  to  draw  it  back  and  expec- 
torate it.  Under  this  treatment,  these  cases  usually  recover 
in  from  six  to  eight  weeks. 

Hypertrophic  Rhinitis. 
(Chronic  Hypertrophic  Catarrh.) 

A  certain  number  of  cases  of  simple  chronic  rhinitis 
are  always  neglected  until  they  have  developed  into  Hyper- 
trophic Rhinitis,  and  will  then  for  the  first  time  be  brought 
to  the  notice  of  the  physician.  Here,  on  examination,  a 
different  clinical  picture  reveals  itself.  Structural  changes 
in  various  degrees  of  development  will  now  be  noticed,  a 
proliferation  of  all  the  normal  mucous  membrane  making 
it  of  increased  size  and  therefore  called  hypertrophic.  The 
glandular  structures  in  the  posterior  nares  and  turbinated 
bodies  are  also  enlarged,  subject  to  the  same  influences  as 
the  membranes  more  anteriorly.  The  secretions  are  now 
thick  and  tenacious,  which  with  the  enlarged  membrane  and 
swollen  turbinates  completely  occlude  the  air  passages,  caus- 
ing difficult  breathing,  giving  the  voice  a  nasal  twang  and 
causes  the  patient  to  become  concerned  about  himself. 

The  parts  most  frequently  involved  are  the  inferior 
turbinated  bodies,  which  are  more  or  less  covered  with 
erectile  tissue  which  is  easily  engorged  and  consequently 
increased  in  size.  For  the  reduction  of  this  engorgement 
the  galvano  cautery  is  frequently  recommended  and  used, 
but  it  must  be  said,  often  to  the  decided  disadvantage  and 


NASAL   CATARRH. 


'■i>7 


discomfort  of  the  patient,  and  not  permanently  removing 
the  disease.  In  chromic  acid  we  have  a  remedy  that  in 
many  cases  will  prove  itself  superior  to  the  cautery,  and  one 
that  is  not  attended  with  its  dangers.  It  has  also  the  advan- 
tage of  being  more  easily  within  the  reach  of  the  general 
practitioner,  for  whose  benefit  these  lines  are  written.  For 
the  purpose  of  removing  the  hypertrophy  of  the  anterior 
portion  of  the  inferior  turbinates,  the  following  technique 
should  be  followed:  The  patient  should  receive  local 
treatment  for  the  active  inflammatory  symptoms,  similar  to 
that  advised  for  simple  chronic  rhinitis,  and  after  these  have 
subsided  the  procedure  will  be  thus :  The  side  of  the  nose 
upon  which  the  operation  is  to  be  performed  should  be 
cocainized  with  a  pledget  of  cotton  saturated  with  a  4% 
solution  of  cocaine.  This  pledget  should  be  brought  into 
close  contact  with  the  hypertrophied  tissue  which  is  to  be 
removed,  and  allowed  to  remain  fully  twenty  minutes.  At 
the  end  of  this  time  the  cotton  will  be  removed  and  the 
membrane  will  be  found  to  be  bleached  and  lying  closely 
in  contact  with  the  bone.  A  few  fibres  of  cotton  should  now 
be  wrapped  about  the  end  of  a  probe  and  dipped  first  into 
the  cocaine  solution  and  afterward  into  powdered  cocaine. 
This  probe  is  then  pressed  rather  firmly  along  the  line  of 
the  proposed  application  to  be  made  with  chromic  acid. 
After  a  few  minutes  of  this  pressure  and  rubbing  along  the 
line  of  the  proposed  application,  the  membranes  are  ready  for 
the  action  of  the  chromic  acid,  and  if  properly  cocain- 
ized, little  or  no  pain  should  be  felt.  There  are  several 
methods  by  which  chromic  acid  may  be  applied.  Several 
chromic  acid  applicators  are  in  the  market,  the  best  of 
which  are  probably  the  Bosworth  and  Sajou.  Instrument 
dealers  can  furnish  these  and  their  mode  of  action  is  evident 
on  inspection.  For  all  practical  purposes  the  cotton  on 
probe  method  is  all  that  can  be  desired.  A  few  fibers  of 
cotton  should  be  wrapped  closely  about  the  end  of  a  probe 
and  slightly  moistened.     A  small  quantity  of  coarsely  pow 


258  NASAL,    CATARRH. 

dered  chromic  acid  should  now  be  placed  on  a  piece  of 
glass,  a  glass  slide  answers  very  well,  and  the  cotton  tipped 
end  of  the  probe  turned  in  it  until  considerable  of  the  acid 
is  entangled  in  the  cotton.     The  area  to  be  cauterized  is 
then  carefully  dried,   to  prevent  the  acid  from   dissolving 
and  spreading  to  adjacent  areas.     The  end  of  the  probe  with 
the  acid,   firmly  pressed  against  the  parts,   is  then  drawn 
back  and  forth  against  the  parts  until  the  increased  resist- 
ance indicates  that  the  tissues  have  been  cauterized  through 
to    the   bone.     The   probe    is    now    withdrawn   and   a    few 
moments  are  allowed  for  the  acid  to  complete  its  work.   The 
patient  now  inclines  his  head  forward,  over  a  basin,  and  the 
nose   is   sprayed   with   Dobell's   solution  to   neutralize   any 
excess  of  acid  which  may  remain  in  the  nose.     The  spraying 
should  be  so  carefully  conducted  that  all  of  the  fluid  flows 
forward  into  the  basin,  and  not  backward  into  the  pharynx, 
as  chromic  acid  is  somewhat  poisonous.     Should  a  portion 
of  the  fluid  pass  into  the  pharynx,  carrying  acid  with  it,  free 
douching  should  be  resorted  to  and  the  patient  instructed 
to  refrain  from  swallowing.     This  operation  is  usually  fol- 
lowed by  considerable  swelling  of  the  operated  area  and 
some  degree  of  nasal  stenosis  will  be  present  on  this  account 
and  the  formation  of  the  scabs.     The  scab  usually  comes 
away  within  a  week  and  smaller  ones  form ;  sometimes  once, 
sometimes  twice.    When  they  have  disappeared,  if  there  is 
no  further  hypertrophy,  the  nose  remains  open  and  unob- 
structed.    The  after  treatment  consists  of  keeping  the  parts 
clean  with  Dobell's  solution,  and  if  pain  or  stenosis  should 
require  it  the  snuff  before  mentioned  may  be  employed. 

Hypertrophies  of  the  posterior  portion  of  the  inferior 
turbinated  bodies  are  best  removed  by  the  use  of  the  snare, 
either  the  Jarvis  or  Bosworth.  In  this  operation  cocaine 
must  not  be  used,  as  it  would  shrink  the  part  to  be  grasped 
by  the  wire  loop  so  much  as  to  make  it  impossible.  By 
a  little  delicate  manipulation  the  operator  will  be  able  to 
grasp  in  the  loop  as  much  of  the  hypertrophied  tissue  as  is 


NASAL    CATARRH.  2jl) 

desired  to  be  removed,  and  by  a  rapid  ringer  pressure  will  be 
able  to  retain  it  until  the  set  screw  can  be  set  upon  it.  By 
a  few  turns  of  the  screw  the  wire  loop  is  tightened  until 
there  is  no  danger  of  slipping.  After  a  few  minutes  rest 
the  screw  is  gradually  turned,  usually  about  one-half  turn 
at  a  time.  Allow  a  rest  of  a  few  minutes  after  each  half 
turn  and  continue  until  the  hypertrophy  is  freed  from  its 
attachments.  The  attaching  of  the  loop  is  really  the  only 
painful  part  of  the  operation  and  as  soon  as  it  is  well  tight- 
ened there  is  but  trifling  pain.  There  is  usually  but  trifling 
hemorrhage,  but  the  patient  should  not  be  allowed  to  leave 
the  office  for  half  an  hour  so  as  to  be  conveniently  near 
should  a  severe  hemorrhage  occur. 

For  the  purpose  of  checking  hemorrhage,  should  it 
occur,  pressure  should  be  applied  to  the  bleeding  vessels. 
A  probe  should  be  wrapped  with  sufficient  absorbent  cotton 
to  form  a  wedge  shaped  plug,  two  inches  long  and  suf- 
ficiently large  to  fill  the  interior  of  the  nose.  Saturate  the 
plug  dripping  wet  with  pure  Hydrozone  and  thrust  it  along 
the  floor  of  the  nose  until  the  pharynx  is  reached.  Place 
the  finger  on  the  cotton  in  the  nose  and  withdraw  the  probe, 
allowing  the  finger  to  remain  on  the  cotton,  under  slight 
pressure,  until  the  ebullition  of  the  gas  which  forms,  has 
subsided.  Support  this  plug  with  another  so  that  the  entire 
space  is  thoroughly  filled  with  the  cotton.  By  the  addition 
of  the  peroxide  to  the  clot  in  the  nose  the  latter  is  hardened 
and  increased  in  size  which  assists  the  cotton  in  forming 
pressure.  It  is  however  not  the  cotton  nor  the  peroxide  that 
suppresses  the  hemorrhage,  but  the  clot  which  forms  firmly 
about  the  cotton  and  extends  into  the  bleeding  vessel.  This 
plug  may  be  carefully  removed  in  from  six  to  twelve  hours. 
In  cases  where  the  hemorrhage  was  unusually  severe  sev- 
eral minutes  should  elapse  between  each  slight  movement 
of  the  plug,  and  if  a  drop  of  blood  appears,  the  cotton 
already  without  the  nose  should  be  clipped  off  and  a  fresh 
Hydrozone  plug  inserted  against  the  stump  of  the  old  one. 


260  NASAL    CATARRH. 

Never  use  Monsell's  solution  or  Monsell's  salt  inside 
the  nose.  It  is  frequently  recommended  in  medical  jour- 
nals, but  is  painful  and  very  irritating.  With  the  Hydro- 
zone  used  as  herein  described,  any  nasal  hemorrhage  can  be 
checked,  even  though  the  plugging  may  have  to  be  repeated 
several  times.  As  before  said,  severe  hemorrhage  is  rare, 
but  as  it  is  the  unexpected  occurrences  which  cause  the 
trouble  it  is  best  to  have  a  remedy  at  hand.  The  after  treat- 
ment is  the  same  as  after  chromic  acid  cauterization — clean- 
liness. 

Atrophic  Rhinitis. 

Atrophic  catarrh,  sometimes  called  Dry  Catarrh,  is 
characterized  by  the  formation  of  dry  scabs  and  crusts,  or 
a  thin  watery  discharge  when  it  occurs  in  scrofulous  per- 
sons. These  scabs,  crusts  and  discharges  usually  emit  a 
fetid  and  offensive  odor.  In  scrofulous  cases  the  disease  is 
termed  ozsena.  This  form  of  catarrh  is  usually  developed 
by  neglecting  to  treat  hypertrophic  catarrh,  and  is  essentially 
a  death  of  the  tissues,  the  tissues  being  crowded  to  death  by 
the  engorgement  and  enlargement  present  in  the  latter  dis- 
ease. There  is  but  little  possibility  of  confounding  this 
stage  of  the  disease  with  any  other.  The  nose  is  now  not 
pressed  for  space.  There  is  no  swelling,  no  engorgement, 
no  hypertrophy.  There  is  no  interference  with  the  breath- 
ing except  that  which  is  caused  by  the  scabs  or  crusts 
present,  the  posterior  wall  of  the  pharynx  will  be  seen  to  be 
dry  and  glistening,  the  sense  of  smell  is  interfered  with  and 
sometimes  destroyed,  there  is  pain  in  the  frontal  sinuses, 
the  patient  is  irritable  and  very  sensitive  to  atmospheric 
changes.  The  odor  escaping  from  the  nostrils  of  persons 
affected  with  this  disease  is  sometimes  beyond  description 
and  must  be  imagined,  rather  than  an  attempt  made  to 
describe  it.  Our  words  of  encouragement  which  we  were 
able  to  express  to  patients  suffering  under  the  forms  of 
catarrh   previously  detailed,  must  now  cease,   for  unfortu 


NASAL    CATARRH.  261 

nately  the  cure  of  this  disease  is  rarely  fully  accomplished. 
The  fetor  of  the  breath  and  the  foul  smelling  discharges  can 
usually  be  easily  and  quickly  corrected,  and  if  the  treatment 
is  persisted  in,  much  good  will  be  accomplished,  and  in 
some  cases  an  apparent  cure  will  result.  The  indications 
for  treatment  are  two- fold;  cleanliness  and  stimulation. 
The  former  may  be  secured  by  the  use  of  the  antiseptic 
wash  before  mentioned,  Dobell's  solution,  although  occa- 
sionally it  will  be  necessary  to  first  remove  the  crusts  and 
scabs  by  means  of  the  forceps.  If  the  removal  of  these 
formations  is  attended  with  much  difficulty,  a  preliminary 
spraying  with  Hydrozone,  50  %,  will  be  of  assistance. 
As  the  pharynx  is  most  frequently  involved  when  this  dis- 
ease exists  to  any  extent,  the  cleansing  should  be  thor- 
oughly done  and  extended  into  this  part  of  the  air  passages. 
For  the  purpose  of  reaching  the  pharynx  a  post  nasal 
syringe  is  best  adapted,  and  after  introducing  the  nozzle 
behind  the  velum  palati,  the  stream  should  be  thrown  into 
the  vault  of  the  pharynx  with  considerable  force.  For  the 
purpose  of  stimulating  the  atrophied  mucous  membranes, 
and  increasing  their  vascularity,  increasing  the  secretions 
and  promoting  new  growth,  various  remedies  have  been 
brought  forward,  the  most  prominent  of  which  are  Nitrate 
of  Silver,  Galangal  Root,  powdered,  Salicylic  Acid  and 
Potassium- Bromide.  In  my  experience  the  first  mentioned 
is  alone  worthy  of  recognition.  It  may  be  employed  either 
in  solution  or  by  means  of  the  powder  blower.  Any  good 
instrument  will  answer  the  purpose,  and  yet  for  general  con- 
venience and  cleanliness  the  DeVilbiss,  with  several  extra 
reservoirs,  is  perhaps  the  one  to  be  preferred.  The  tube 
and  reservoirs  are  of  metal  and  can  thus  be  easily  cleansed. 
If  applied  in  solution  the  applications  are  made  by  means 
of  the  cotton  tipped  probe,  in  sufficient  strength  to  produce 
momentary  smarting.  The  strength  may  vary  from  five  to 
thirty  grains  of  the  Silver  Nitrate  to  the  fluid  ounce  of 
distilled  water. 


21)2  NASAL    CATARRH. 

For  use  in  the  powder  blower  the  Nitrate  of  Silver 
should  be  used  in  strength  sufficient  to  produce  the  same 
effect  as  in  solution,  momentary  smarting.  As  a  diluting 
agent  starch  may  be  used  and  the  strength  may  vary  from 
ten  to  thirty  grains  to  the  ounce  of  starch.  Stearate  of  Zinc 
is  a  very  desirable  vehicle  for  the  body  of  a  snuff,  as  it  is 
very  light  and  extremely  tenacious.  As  it  is  lighter  and 
more  bulky  than  starch,  two  drachms  may  be  used  instead 
of  one  ounce  of  starch.  These  stronger  applications  should 
be  made  by  the  physician  twice  or  three  times  each  week, 
while  for  the  home  use  of  the  patient  he  should  be  given  a 
preparation  containing  about  three  grains  of  the  Nitrate  of 
Silver  to  the  ounce  of  Starch  or  two  drachms  Stearate  of 
Zinc.  Directions  should  be  given  to  use  it  as  a  snuff  at 
bedtime,  each  night.  An  important  part  of  the  treatment 
of  Atrophic  Rhinitis  is  the  wearing  of  cotton  plugs  or  cylin- 
ders in  the  nose,  so  placed  inside  the  nose  as  to  take  the 
place,  to  a  large  extent,  of  the  atrophied  turbinated  bodies. 
Their  presence  excites  the  atrophied  mucous  membrane  to 
renewed  action,  so  that  the  dried  secretions  are  washed 
away  in  the  increased  discharges,  and  the  fetid  odor  cor- 
rected. The  air  passing  through  and  around  these  cylinders 
becomes  warmed,  moist  and  free  from  dust  and  enters  the 
lungs  as  if  it  had  passed  through  a  health}-  nose.  If  the 
pharynx  presents  an  atrophied  condition  these  cylinders  of 
absorbent  cotton  should  be  sufficiently  long  to  extend  the 
entire  length  of  the  nasal  floor  and  project  somewhat  from 
the  posterior  nares.  These  cylinders  are  easily  made  by 
loosely  wrapping  absorbent  cotton  about  a  smooth  probe 
until  it  has  assumed  the  desired  shape  and  bulk,  when  it  may 
be  slipped  off  the  probe  and  introduced  into  the  nose,  or  it 
may  be  introduced  with  the  probe  and  slipped  off  afterward. 
The  patient  may  be  taught  how  to  make  these  cylinders  and 
instructed  to  introduce  a  fresh  one  as  soon  as  the  old  one  is 
removed  by  the  use  of  the  handkerchief.  As  the  secretions 
are  absorbed  by  the  cotton  the  breathing  becomes  more  dif- 


NASAL    CATARRH.  263 

ficult,  and  when  it  seems  filled  a  fresh  one  should  be  inserted. 
Note  that  these  cylinders  are  to  be  loosely  wrapped,  so  as 
to  allow  free  breathing  through  them.  If  worn  constantly 
the  improvement  will  be  immediately  noticed.  When  the 
pharynx  is  involved,  in  addition  to  allowing  the  cotton  cylin- 
ders to  extend  slightly  beyond  the  posterior  nares,  applica- 
tions of  Nitrate  of  Silver  in  solution,  grs.  v  to  xv  to  the 
ounce  of  distilled  water,  should  be  made  to  the  atrophied 
mucous  membrane,  three  times  a  week,  to  stimulate  the 
atrophied  glands  to  increased  secretion  and  induce  renewed 
growth  in  the  atrophied  structures. 

Internally,  to  increase  secretions  and  lessen  reflex  irri- 
tability, the  following  mixture  may  be  used  to  advantage : 

^      Potassium    Bromide 3  iv. 

Potassium    Iodide 5  iss. 

Ext.    Glycyrrhiza 5  iss. 

Aqua q.  s.  ad.  fl.  5  iv. 

M.     Sig.     Teaspoonful  before  each  meal. 


Additional  Formulae. 

The  formula  given  for  Dobell's  solution  is  a  somewhat 
modified  form  of  the  official  preparation,  which  is  as  follows  : 
I£      Sodium  Bicarbonate. 

Sodium    Biborate aa  5  ij. 

Acid    Carbolic gtt.  xxiv. 

Aqua    q.  s.   ad.  Oj. 

Mix. 

A  great  many  modifications  of  this  formula  frequently 
appear  in  medical  periodicals,  all  of  which  practically  answer 
the  purpose  for  which  they  are  intended,  although  the  one 
given  under  Simple  Chronic  Rhinitis  is  perhaps  the  most 
popular  and  has  the  advantage  of  having  a  specific  gravity 
practically  the  same  as  blood  serum. 


264  NASAL   CATARRH. 

Instead  of  using  cocaine  in  the  form  of  a  snuff  it  is  per- 
missible to  combine  it  in  the  form  of  an  ointment.  It  is 
useful  in  Simple  Chronic  Rhinitis  and  in  Hypertrophic 
Rhinitis,  but  should  be  used  with  caution ;  not  dispensing 
more  than  one-fourth  or  one-half  ounce  at  a  time  and  never 
allowing  the  patient  to  know  that  cocaine  is  being  used.  It 
should  not  be  continued  any  longer  than  the  time  required 
to  treat  the  patient  as  heretofore  outlined,  and  it  should  only 
be  considered  as  an  adjunct,  as  a  palliative,  and  not  as  a 
curative  agent.  The  following  formula  will  be  found  pleas- 
ant and  effective  in  allaying  irritability  and  temporarily 
reducing  the  engorgement  and  hypertrophy : 

I?      Cocaine    Muriate gr.  xij. 

Thymol    gr.  viij. 

Menthol    gr.  xij . 

White    Petrolatum 3  iv. 

Mix. 

Sig.  Apply  a  piece  the  size  of  a  pea,  well  up  into  the 
nostril.     Repeat  once  or  twice  daily. 

In  the  treatment  of  Simple  Chronic  Rhinitis,  the 
strength  of  the  Iodine,  Iodide  of  Potassium  and  Glycerine 
mixture  can  be  varied  according  to  the  requirements  of  the 
patient.  The  formula  given  is  usually  a  good  one  to  begin 
with  and  as  soon  as  the  patient  becomes  accustomed  to  this 
strength  and  it  no  longer  causes  smarting  when  applied,  the 
strength  of  the  Iodine  and  Iodide  of  Potassium  may  be 
increased  to  as  much  as  thirty  grains  of  the  former  and 
ninety  grains  of  the  latter  to  the  ounce  of  glycerine. 

The  following  formula  may  be  used  alternately  with 
the  Iodine-Iodide  of  Potassium  solution,  especially  when  the 
lower  portion  of  the  pharynx  is  involved  : 

^     Fl.  Ext.  Hydrastis  Canaden fl.  3  iv. 

Glycerine q.  s.  ad.  fl.  §  ij. 

Mix. 


NASAL    CATARRH.  265 

After  the  local  treatment  by  the  physician  is  discon- 
tinued, the  patient  should  be  instructed  to  continue  the  use 
of  the  atomizer  with  the  alkaline  and  antiseptic  solution  for 
a  month  or  more.  Thorough  cleansing  of  the  nose  and 
pharynx,  twice  a  day  should  be  insisted  on,  and  the  follow- 
ing ointment  used  afterward.  This  ointment  is  perfectly 
harmless,  even  if  continued  indefinitely : 

^     Menthol   gr.  j. 

Thymol    gr.  ii j . 

Bismuth  Sub  Carbonate gr.  xv. 

Oil    Gaultheria gtt.  ij. 

White  Petrolatum 5  j  • 

Mix  thoroughly. 

Apply  to  nostril  after  using  atomizer. 


A  Stimulating  Powder. 

I£     Acid    Boracic 3  iv. 

Sulphur   lact 3  ij. 

Fl.  Ext.  Calendula gtt.  xxx. 

Mix.  Triturate  well  in  a  mortar  and  spread  on  paper 
and  allow  it  to  dry.  Triturate  again  and  bottle.  Apply 
with  powder  blower. 

In  preparing  solutions  of  Nitrate  of  Silver  always  use 
distilled  water,  as  the  salts  of  calcium,  potassium,  etc.,  found 
in  water  combine  with  it  and  render  it  less  efficacious. 

If  the  treatment  of  these  commoner  affections  of  the 
upper  air  passages  will  be  faithfully  followed,  any  practi- 
tioner can  confidently  expect  to  realize  results  fully  as  sat- 
isfactory as  those  obtained  by  the  specialist,  bearing  in  mind 
always  that  the  specialist  is  nothing  more  than  a  physician 
who  has  acquired  a  thorough  knowledge  of  his  subject,  and 
what  is  perhaps  more  to  the  point,  has  the  courage  to  put 
his  knowledge  to  a  practical  application. 


266  NASAL    GROWTHS. 


Other  Nasal  Abnormalities. 

The  physician  who  has  become  thoroughly  acquainted 
with  the  treatment  of  the  Catarrhal  conditions  of  the  air 
passages,  has  but  a  short  step  to  make  to  be  able  to  handle 
successfully  some  of  the  minor  surgical  conditions  that  are 
frequently  met  with  in  a  practice  devoted  largely  to  the 
treatment  of  diseases  of  the  nose  and  throat.  These  will 
occupy  our  attention  briefly. 

Nasal  Polypi. 

A  very  frequent  cause  of  nasal  stenosis  and  difficult 
breathing  is  nasal  polypi,  of  which  there  are  three  varieties : 
mucous,  fibrous  and  cystic.  The  most  common  varieties 
are  the  mucous  and  the  fibrous.  The  cystic,  which  is  noth- 
ing more  than  a  thin  bladder  like  sac,  filled  with  a  thin 
watery  substance,  is  extremely  rare.  Polypi  are  easily  rec- 
ognized. They  are  usually  somewhat  paler  in  color  than 
the  mucous  membrane,  and  are  pedunculated.  The  mucous 
polypus  is  soft,  gelatinous  and  increases  in  size  in  damp 
weather.  The  fibrous  polypus  is  harder,  more  firm  and  on 
section  shows  a  more  solid  structure  than  the  mucous.  They 
are  a  frequent  cause  of  reflex  disturbances,  the  most  notable 
of  which  is  asthma.  Many  asthmatic  cases  recover  entirely 
after  the  removal  of  nasal  polypi.  These  growths  are  easily 
removed,  so  easily  in  fact  that  it  is  surprising  to  learn  of  the 
number  of  physicians  who  would  not  hesitate  to  amputate  a 
limb  or  curette  a  uterus,  and  yet  refer  cases  of  nasal  polypi 
to  the  nose  and  throat  specialist. 

A  polypus  is  devoid  of  any  sensibility,  but  its  attach- 
ment is  often  extremely  sensitive,  and  therefore  their 
removal  should  not  be  attempted  without  the  use  of  cocaine. 
The  instrument  used  is  the  wire  snare,  of  which  several 
styles  are  in  the  market,  and  which  have  previously  been 
referred  to  in  this  chapter.     If  the  polypus  is  small  it  should 


NASAL   GROWTHS.  267 

be  encircled  and  slightly  compressed  by  the  wire  before  the 
cocaine  is  applied,  as  if  this  is  not  done,  the  polypus  will 
often  disappear  under  the  influence  of  the  cocaine.  Their 
removal  is  accomplished  in  the  same  manner  as  detailed 
under  the  removal  of  the  hypertrophied  tissue  from  the  tur- 
binates. If  the  parts  are  not  thoroughly  cocainized  there 
will  usually  be  considerable  sneezing  on  the  part  of  the 
patient,  greatly  to  the  annoyance  of  the  operator  and  possible 
harm  to  the  tissues,  especially  after  the  snare  has  been  partly 
tightened.  The  removal  of  polypi  is  usually  attended  with 
but  little  loss  of  blood  and  under  proper  anesthesia  is  not 
painful.  After  these  growths  have  been  removed  and  the 
nose  cleared,  the  stumps  should  be  dusted  with  powdered 
pepsin,  caroid  or  papoid,  that  the  tissue  devitalized  by  the 
pressure  of  the  snare  may  be  digested  and  the  surface  freed 
from  dead  or  partly  dead  fragments.  It  has  been  claimed 
that  applications  of  strong  solutions  of  pepsin  or  the  other 
digestants  mentioned  have  the  power  to  digest  polypi,  but 
this  statement  is  not  borne  out  by  experience.  Polypi  are 
usually  recurrent  but  repeated  removal  and  proper  attention 
to  the  stumps  will  after  a  time  render  the  patient  free  from 
these  growths.  After  the  removal  of  them,  other  conditions 
if  present  should  be  treated  as  indicated.  The  removal  of 
polypi  is  often  only  the  first  step  in  the  treatment  of  the 
various  forms  in  which  catarrh  appears. 

Fibroma. 

Fibrous  tumors  are  sometimes  met  with  in  the  naso- 
pharyngeal region,  and  when  found  should  be  promptly 
removed.  Fibromata,  as  indicated  by  their  name,  are  tough 
fibrous  growths  with  considerable  vascularity. 

Their  removal  is  best  accomplished  by  the  galvano- 
cautery  snare,  with  its  wire  at  a  red  heat.  The  operation 
should  not  be  attempted  with  the  ordinary  snare  as  the  best 
steel  wire  usually  breaks,  and  the  hemorrhage  is  quite  pro- 
fuse. The  hot  wire  acts  as  a  hemostat  and  thus  adds  another 
feature  to  its  value.     Cocainize  thoroughly. 


268  NASAL   INSTRUMENTS. 


Instruments. 

In  the  fore  part  of  this  chapter  we  referred  to  a  few 
instruments  that  are  absolutely  necessary  for  the  purpose  of 
making  even  a  most  superficial  examination  of  the  nose  or 
throat.     These  and  others  will  now  be  more  fully  considered. 

Instruments  for  Making  Examinations. 

The  Lamp.  When  the  office  is  supplied  with  gas,  the 
adjustable  Gas  Bracket  with  Argand  Burner  is  a  very  desir- 
able light,  or  the  Boekel-Mackenzie  Laryngoscope  with 
Mirror  Bar  and  Mirror  may  be  used.  With  the  former  the 
head  mirror  is  used  while  with  the  latter  the  mirror  is 
attached  to  the  bar  and  lamp,  thus  leaving  the  head  of  the 
operator  free.  The  latter  instrument  can  also  be  obtained 
for  use  on  an  oil  lamp  for  which  purpose  the  lamp  known  as 
the  "Student,"  is  best  adapted. 

Head  Mirror.  While  this  instrument  is  not  used  in 
connection  with  the  Laryngoscope  previously  mentioned, 
every  physician  doing  work  along  this  line  should  be  sup- 
plied with  one.  Examinations  may  often  be  made  by  sun 
light  and  when  this  is  possible  it  is  always  most  satisfactory. 
A  number  of  different  styles  of  head  mirrors  and  bands  are 
ir?  the  market,  all  of  which  are  practically  the  same.  Electric 
lights  with  mirror  attached  are  in  the  market,  and  are  a  con- 
venient article.  See  portable  electric  light  outfit  in  section 
on  Rectal  Diseases. 

Nasal  Specula.  The  most  desirable  instrument  for 
dilating  the  nostril  is  one  that  is  self-retaining,  thus  leaving 
both  hands  of  the  operator  free.  Several  of  this  kind  are 
in  the  market,  the  best  of  which  are  probably  Potter's, 
Bosworth's,  Frankel's,  Goodwillie's,  or  Folsom's,  all  of 
which  are  similarly  constructed  and  have  their  advocates. 

Several  different  Specula  should  be  bought  to  meet  the 
requirements  of  different  cases. 


NASAL,  INSTRUMENTS.  269 

Tongue  Depressors  are  found  in  various  shapes  and 
styles,  all  of  which  practically  answer  the  purpose.  The 
ordinary  fenestrated  instrument  which  folds  and  is  thus 
easily  tucked  away  and  carried  is  all  that  can  be  desired. 

Laryngeal  Mirrors  are  made  in  different  sizes  and  sev- 
eral should  be  purchased. 

Operating  Instruments. 

Snares.  The  general  principle  of  all  snares  is  alike. 
Some  are  more  elaborate  than  others  but  have  no  practical 
advantage  over  the  simpler  forms.  As  an  all-around  instru- 
ment the  Bosworth  snare  is  a  perfect  success.  The  Hooper, 
Jarvis  and  the  Wright  may  also  be  mentioned.  The  latter 
is  a  more  complicated  affair,  and  instead  of  a  nut  for  tight- 
ening the  snare,  it  has  a  small  lever,  which  on  being  pressed, 
slips  a  serated  attachment  over  a  retaining  point,  one  notch 
at  a  time.     It  also  can  be  folded. 

Gaevano-Cautery.  Any  instrument  house  can  fur- 
nish these  instruments  in  scores  of  different  designs  and 
styles,  depending  largely  on  the  amount  which  the  physician 
wishes  to  invest.  The  Galvano-Cautery,  while  as  before  said 
is  often  used  injudiciously,  is  nevertheless  a  desirable  instru- 
ment, and  in  proper  hands  will  accomplish  much  good.  A 
follicular  pharyngitis  will  almost  invariably  follow  the  free 
use  of  the  cautery,  and  treatment  should  be  instituted  at  the 
first  symptom. 

A  Compressed  Air  Apparatus  may  be  added  for  office 
work,  also  the  necessary  Nebulizers,  Vaporizers  and  Atom- 
izers. A  liberal  supply  of  applicators,  probes,  retractors, 
post-nasal  syringes,  powder  blowers,  etc.,  etc.,  should  be 
kept  on  hand. 

Other  instruments  will  be  required  from  time  to  time 
as  the  physician  proceeds  with  his  work,  depending  entirely 
on  the  particular  cases  he  may  be  called  upon  to  treat. 


27O  DISEASES    OF    WOMEN. 


DISEASES  OF  WOMEN 


Non-Surgical  Treatment. 


The  treatment  of  diseases  of  women  will  forever  con- 
stitute an  important  and  considerable  portion  of  the  practice 
of  the  general  practitioner,  and  if  special  attention  is  given 
to  this  class  of  cases,  the  additional  financial  returns  that  will 
accrue  will  amply  repay  any  physician  for  the  extra  time  and 
thought  devoted  to  them. 

In  considering  this  subject  it  should  be  understood  that 
the  necessary  surgical  means,  often  so  successfully  resorted 
to  in  cases  in  which  surgery  is  undoubtedly  indicated,  are 
not  under-estimated  or  discouraged,  but  the  fact  remains 
that  after  one  or  two  successful  operations  on  the  female 
generative  organs  have  taken  place  in  any  locality,  there  will 
be  the  usual  rush  for  operations  and  it  will  continue  unin- 
terruptedly until  one  or  more  sudden  deaths  effectually  quell 
the  onslaught.  Under  such  circumstances  the  physician 
is  apt  to  be  carried  on  with  the  swell  of  the  tide  and  begins 
to  think  that  after  all,  surgery  is  the  only  remedy.  The 
gynecologist  is  never  consulted  in  these  cases  until  after 
the  patient  has  been  ineffectually  treated  by  one  or  more 
general  practitioners,  and  it  is  for  the  latter  class  of  physi- 
cians to  decide  whether  the  gynecologist  is  to  be  consulted 
or  not.  On  the  treatment  given  by  the  family  physician, 
or  some  other  physician  in  general  practice,  depends  largely 
the  future  course  of  the  woman  afflicted  with  diseases  pecu- 
liar to  her  sex,  and  it  is  therefore  important  that  sufficient 
attention  should  be  given  the  subject  to  at  least  treat  them 
with  intelligence  and  the  best  means  known  to  the  profes- 


DISEASES    OF    WOMEN.  2.JI 

sion.  When  the  indication  for  surgery  is  unmistakable, 
no  time  should  be  lost  in  obtaining  the  necessary  operation, 
but  when  the  indication  for  this  is  not  clear  or  entirely 
absent,  much  good  can  be  accomplished  by  other  remedial 
means. 

The  conditions  met  with  in  an  ordinary  practice  of  this 
kind  are  Dysmenorrhoea,  Leucorrhoea,  Vaginitis,  Pruritus, 
Prolapse,  Ulcerations,  Irritability  of  the  Bladder,  Backache, 
Bearing-down  feeling.  Ovaritis  and  Pain. 

Examination  of  women  in  whom  this  condition  of 
affairs  exists  will  almost  invariably  reveal  enlargement  of  the 
womb,  either  hard,  or  soft  and  flabby,  thickening  of  the 
mucous  membranes,  inflamed  and  engorged  when  in  the 
earlier  stages  and  hardened  and  tough  in  the  latter  stages, 
and  thickening  of  the  peritoneal  coverings  and  adhesions, 
the  latter  being  at  times  noticeable  through  the  vaginal 
walls  and  demonstrable  in  surgical  cases. 

Similar  conditions  occurring  in  other  parts  of  the  body 
would  at  once  call  for  a  remedy  that  strangely  is  but  seldom 
seen  recommended  in  the  treatment  of  female  diseases.  The 
remedy  is  Iodine.  This  drug  is  the  best  at  our  command 
to  increase. tissue  waste  and  absorption  of  all  hypertrophied 
or  indurated  mucous  membranes  and  combined  with  other 
remedies  that  may  be  indicated,  the  results  are  often  sur- 
prising. The  following  can  confidently  be  relied  on  and  is 
especially  indicated  where  there  is  leucorrhoea,  back-ache, 
dysmenorrhoea  or  amenorrhoea,  irritability  of  the  bladder 
and  pain. 

1^      Iodine,  resublimed gr.  xl. 

Potassium   Iodide gr.  lxxx. 

El.  Ext.  Nux  Vomica. 
El.  Ext.  Belladonna. 

Tr.  Cantharides aa  fl.  5  ij. 

Aqua q.  s.  ad.  fl.  %  ij. 

Mix.  Dissolve  the  Iodine  in  a  solution  of  the  Iodide  of 
Potassium   in  the  water,  and  add  to  the  other  ingredients. 


2J2  DISEASES    OF    WOMEN. 

Let  stand  a  week  or  ten  days,  filter,  and  it  is  ready  for  use 
Dose,  ten  to  fifteen  drops,  in  water,  three  times  a  day, 
preferably  before  meals. 

When  the  leucorrhoea,  back-ache  and  irritability  of  the 
bladder  disappear  the  treatment  should  be  changed  and  only 
the  iodine  and  potassium  iodide  need  be  given.  Use  the 
same  quantities  as  above  given,  in  two  ounces  of  water,  dose 
being  the  same.  Continue  this  until  the  enlargement  and 
thickening  of  the  membranes  also  disappears  or  reaches 
the  limit  of  improvement.  When  amenorrhoea  is  the  prin- 
cipal symptom,  the  Iodine  and  Iodide  of  Potassium  mixture 
need  only  be  given  fifteen  days  prior  to  the  time  for  men- 
struation. It  will  prove  itself  an  efficient  emmenagogue 
whenever  a  remedy  of  this  sort  is  indicated.  Instead  of  add- 
ing all  water,  syrup  or  simple  elixir  may  be  added  to  im- 
prove the  taste.  By  adding  vehicles  of  this  sort  the  above 
formula  may  be  increased  to  eight  ounces,  when  the  dose 
would  be  one  drachm. 

If  the  patient  requires  a  sedative,  Hyoscyamus  or  Vi- 
burnum, or  both  may  be  added  to  the  above,  or  Tr.  Gentian 
Comp.,  should  the  appetite  need  stimulation.  In  order  to 
obtain  the  best  results  it  will  be  necessary  to  continue  this 
treatment  for  from  six  months  to  a  year,  according  to  the 
gravity  of  the  case.  Iodine  promotes  absorption  as  is  well 
known,  but  it  is  essentially  a  slow  process.  Under  this  treat- 
ment the  entire  system  is  benefited,  especially  when  the 
menstrual  flow  is  retarded  as  it  relieves  the  system  of  the 
effete  material  which  is  allowed  to  accumulate. 

Iodine  stimulates  to  glandular  activity  and  consequently 
the  ovaries  are  influenced  by  it.  The  glands  in  the  mucosa 
of  the  uterus  as  well  as  the  numerous  pelvic  glands  are  also 
stimulated  to  their  normal  action. 

Iodine  is  usually  better  borne  than  the  large  doses  of 
Iodide  of  Potassium  which  would  be  necessary  to  obtain  the 
required  amount  of  Iodine,  and  does  not  retard  the  diges- 
tion as  does  the  Iodide,  and  in  fact  in  many  cases  the  appe- 


DISEASES   OF    WOMEN.  273 

tite  is  materially  increased.  Where  small  fibroids  of  the 
uterus  are  known  to  exist,  Iodine  administered  in  connec- 
tion with  Ergot  will  sometimes  cause  them  to  be  passed 
with  the  menstrual  flow.  The  Ergot  should  not  be  com- 
bined with  the  Iodine,  but  should  be  given  at  an  interval  of 
an  hour  or  two  after  the  latter.  The  dose  depends  upcn  the 
preparation  employed,  whether  fluid  extract,  solid  extract 
or  ergotin,  and  the  physician  may  be  guided  in  this  matter 
by  the  customary  dosage  of  the  preparation  employed. 

In  cases  of  prolapse,  ulceration,  erosion  of  the  cervix, 
leucorrhoea,  pruritus  or  small  polypi  the  following  wafer  will 
be  found  an  exceptionally  good  remedy.  They  do  not  cause 
any  burning  or  stinging  when  introduced  into  the  vagina 
and  are  decidedly  antiphlogistic.  In  cases  where  there  is 
much  ulceration  with  oedema  or  polypi  the  discharges  will 
be  found  to  contain  more  or  less  shreds  of  mucous  mem- 
brane or  the  polypi,  and  the  patient  should  be  informed  of 
this  fact  in  order  that  she  may  not  be  frightened  when  she 
notices  it.    The  formula  is  as  follows : 

I£     Powd.  Zinc  Sulphate gr.  xxx. 

Powd.  Jequerity  Seed 3  iij. 

Powd.  Acacia 3  j. 

Powd.  Acid  Boracic 3  x. 

Aqua q.  s. 

Mix.  Divide  into  60  wafers,  or  compress  into  60  flat 
tablets. 

Rub  the  powdered  ingredients  together  in  a  mortar 
until  intimately  mixed  and  add  sufficient  water  to  make  a 
mass  of  about  the  same  consistency  as  a  pill  mass.  Roll 
the  mass  on  a  tile  and  cut  into  sixty  pieces.  Flatten  each 
piece  into  the  shape  of  a  coin  and  set  aside  to  dry.  Wafers 
made  by  this  process  harden  more  solidly  than  when  made 
by  compression  of  the  dry  powder,  and  therefore  will  not 
dissolve  as  quickly;  a  desirable  point. 

Directions.     Direct  the  patient  to  take  a  douche  of  hot 


2/4  DISEASES    OF    WOMEN. 

water  and  after  an  interval  of  half  an  hour,  insert  a  wafer 
into  the  vagina,  well  up  against  the  womb.  Allow  it  to 
remain  three  days,  then  take  another  douche.  Wait  twenty- 
four  hours  and  repeat  the  process  and  continue  thus  through- 
out the  time  required,  as  long  as  relief  and  improvement  is 
obtained. 

It  should  not  be  inferred  that  this  treatment  will  cure 
all  cases  of  prolapse  of  the  uterus,  but  by  the  tonic  and 
astringent  action  of  this  remedy  the  vaginal  walls  will  become 
less  lax  and  shrunken  and  will  thus  afford  a  better  support 
for  the  womb.  The  sole  cause  for  prolapse  is  often  the  pre- 
viously mentioned  engorgement  and  enlargement,  which 
being  relieved  will  allow  the  womb  to  assume  its  normal 
shape  and  position. 

In  simple  leucorrhoea,  vaginitis  or  pruritus  the  follow- 
ing astringent  powder  will  be  found  of  the  highest  value : 

H      Powd.  Alum. 

Powd.  Boracic  Acid. 

Powd.  Sodium  Biborate aa        %  xvj. 

Acid  Carbolic fl.  3  iiss. 

Oil  Gaultheria   fl.  3  ss. 

Mix. 


Mix  the  Carbolic  acid  with  the  Oil  and  add  the  other 
ingredients.  If  there  is  much  fetor  of  the  discharge  Potas- 
sium Permanganate  may  be  added  in  the  proportion  of  gr. 
xv  to  gr.  xxx  to  the  pound. 

Sig.  One  to  two  heaping  teaspoon fuls  to  a  pint  of  hot 
water.  Use  as  a  douche  once  or  twice  daily.  For  the  pur- 
pose of  douching  the  ordinary  small  vaginal  tubes  furnished 
with  syringes  are  practically  worthless.  Use  a  fountain 
syringe  of  at  least  one  quart  capacity,  with  a  dilating  nozzle 
ris  shown  in  the  following  illustrations. 


DISEASES    OF    WOMEN. 


-/b 


m 


The  "Niagara  Spray"  Dilating  Nozzle.    (Closed). 
With  and  without  return  flow. 


By  means  of  this  instrument  the  vagina  is  thoroughly 
dilated,  folds  of  the  mucous  membrane  which  enclose  and 
retain  secretions  are  opened  and  the  antiseptic  cleansing 
douche  distributed  to  all  parts  of  the  vagina.  An  additional 
advantage  is  gained  by  not  having  the  openings  in  the  tube 
in  contact  with  the  vagina.     By  means  of  the  dilators  the 


2/6 


DISEASES  OF    WOMEN. 


■V  ■■■■ 


The  "Niagara  Spray"  Dilating  Nozzle.    (Open). 
With  and  without  return  flow. 


vaginal  membrane  is  at  all  times  from  three- fourths  to 
one  inch  distant  from  the  outlet  of  the  tube,  thus  allowing  a 
forcible  contact  of  the  douche  against  the  vagina.  Douches 
given  with  the  ordinary  small  tube  cannot  compare  in 
effectiveness  with  the  thorough  cleansing  and  medication 
possible  with  this  spray. 

By  means  of  the  return  flow  attachment,  a  thorough 
douching  can  be  given  in  bed,  or  without  soiling  the  clothing. 


DISEASES   OF    WOMEN.  277 


Pruritus. 

The  obstinacy  of  this  symptom  warrants  a  somewhat 
more  extended  consideration.  When  it  is  present  the  urine 
should  always  be  carefully  examined,  as  it  is  known  to  be  a 
frequent  symptom  of  Diabetes. 

If  no  constitutional  cause  can  be  ascertained  the  fol- 
lowing remedies  will  in  many  instances  give  relief.  The 
formulae  given  for  Pruritus  Ani  may  also  be  employed. 

Applications  of  tar  water  to  which  one  per  cent,  of 
chloral  hydrate  and  acetic  acid  have  been  added  should  be 
used  as  a  lotion  to  the  vulva,  morning  and  evening.  Also 
the  following  ointment : 

T£      Menthol gr.  xlv. 

Olive  Oil gtt.  xv. 

Lanoline 3  iss. 

Mix.    Apply  after  the  lotion  above  mentioned. 
Or    1^     Potassium  Bromide. 

Acid  Salicylic aa  gr.  xv. 

Glycerole  of  Starch 3  v. 

Calomel gr.  vj. 

Powd.  Ext.  Belladonna gr.  iij. 

Mix. 

Or    IJ     Acid  Carbolic 3  j. 

Morphia  Sulphate gr.  x. 

Acid  Boracic 3  ij. 

Vaseline 0  iiss- 

Mix. 
Or    1^     Cod  Liver  Oil. 
Oil  of  Tar. 

Lanoline aa  3  ijss. 

Silver  Nitrate    gr.  vj. 

Mix. 

Electricity,  both  Faradic  and  Galvanic  current,  is  some- 
times employed  with  good  results. 


2/8  TAPE    WORMS. 


TAPE  WORMS. 


In  man  the  normal  habitat  of  the  parasite  of  the  genus 
Tenia,  commonly  known  as  the  Tape  Worm,  is  in  the  small 
intestine,  where  it  flourishes  under  all  normal  or  abnormal 
physical  conditions,  its  spontaneous  expulsion  rarely  if  ever 
occurring.  The  symptoms  of  a  person  harboring  one  of  these 
unwelcome  guests  are  sometimes  serious  and  at  others  less 
troublesome.  There  may  be  any  of  the  following  symptoms  : 
loss  or  increase  of  appetite,  melancholia,  nausea,  vomiting, 
colic,  insomnia,  headaches  from  intestinal  irritation,  etc.  The 
only  certain  indication  of  the  existence  of  the  worm  is  the 
passage  with  the  stool  of  the  links  or  sections  of  the  worm, 
which  appear  and  are  often  described  by  patients  as  pieces  of 
gristle. 

Tape  Worm  Specialists. 

The  medical  profession  is  largely  responsible  for  the 
existence  and  success  of  the  gentry  known  as  "Tape  Worm 
Specialists."  This  class  of  practitioners,  who  are  often 
irregulars  and  non-graduates,  are  frequently  permanently 
located  in  the  large  cities,  or  are  of  the  itinerant  order  and 
travel  from  one  section  to  the  other. 

It  is  a  great  mistake  on  the  part  of  the  general  profes- 
sion to  ignore  the  symptoms  produced  by  tape  worms,  or 
to  refuse  to  attempt  to  treat  persons  thought  to  have  one  or 
more  of  them,  for  the  reason  that  itinerants  and  charlatans 
deal  with  these  parasites.  If  the  profession  would  devote 
some  attention  to  these  cases  and  treat  them  intelligently, 
the  presence  of  the  "Tape  Worm  Specialist"  would  become 
exceedinsflv  rare. 


TAPE     WORMS.  279 

THE  REMEDY. 

When  physicians  desire  to  administer  medicines  for  the 
removal  of  tape  worms  they  are  often  at  a  loss  to  know  what 
to  prescribe,  use  inferior  drugs,  and  often  fail  in  their  efforts. 
The  following  remedy  was  obtained  from  a  physician  who 
used  it  with  a  great  deal  of  success,  claiming  that  when  good 
drugs  are  used  the  remedy  was  practically  a  specific.  In 
my  own  practice  I  have  had  occasion  to  use  the  remedy  and 
I  feel  safe  in  asserting  that  seventy-five  per  cent,  of  all  cases 
will  be  permanently  relieved,  passing  the  worm  entire,  while 
others  will  receive  temporary  relief,  and  can  be  treated  again 
in  about  ninety  days.  Treatment  should  not  be  repeated 
earlier  than  ninety  days  after  a  treatment  has  been  given, 
or  until  sections  of  the  worm  pass  in  the  feces.  It  requires 
about  this  period  for  a  worm  to  become  full  grown.  Should 
sections  pass  from  a  patient  after  a  worm  or  part  of  one  has 
been  removed,  it  is  an  indication,  that  a  second  worm  is 
present,  and  treatment  may  be  given  within  a  week  or  two. 
The  formula  is 

I£     Oleoresin  Male  Fern,  (Squibb) 3  iij. 

Fl.  Ext.  Kamala 5  ij. 

Chloroform gtt.  x. 

Croton  Oil gtt.  iij. 

Castor  Oil q.  s.  ad.  %  ij. 

Mix. 

This  quantity  is  to  be  divided  into  two  portions  of  one 
ounce  each  and  taken  as  directed  in  the  following  paragraph. 

Before  administering  the  remedy  a  saline  aperient  should 
be  taken.  Saline,  because  these  cause  a  copious  secretion  of 
fluids  from  the  entire  intestinal  tract.  This  effusion  taking 
place  from  the  surface  where  the  head  of  the  worm  rests, 
protected  by  dense  mucus,  loosens  the  mucus  and  washes  it 
away,  thus  allowing  the  remedy  to  come  into  contact  with 
the  head.  Otherwise  it  would  pass  over  it  without  direct 
contact  and  would  not  cause  the  head  to  pass. 


280  TAPE     WORMS. 

The  saline  should  be  given  about  thirty-six  hours  before 
the  remedy  is  to  be  given,  and  in  the  meantime  the  patient 
should  eat  as  little  as  possible.  The  less  eaten  the  better.  One 
dose  of  the  remedy  should  be  given  at  about  7  A.  M.,  and  the 
second,  two  hours  later.  The  worm  will  come  with  the 
cathartic  action  of  the  remedy.  When  the  worm  is  known 
to  be  passing  the  patient  must  sit  over  a  vessel  containing 
warm  water,  about  the  normal  temperature  of  the  body,  the 
anus  being  in  the  water.  The  worm  will  pass  more  easily 
by  this  method  as  the  change  in  temperature,  when  the  vessel 
is  not  used  causes  the  worm  to  make  an  effort  to  remain 
inside.  When  the  worm  is  dead  this  is  of  course  not  neces- 
sary, but  they  are  not  always  dead  when  passed. 


Tannate  of  Peujetierinf,  is  a  remedy  that  is  largely 
used  and  strongly  recommended  for  the  purpose  of  removing 
tape  worms.  Pelletierine  is  the  active  principle  of  Pome- 
granate.   The  following  formula  will  prove  effective : 

I£     Pelletierine  Tannate gr.  iv. 

Oleoresin  Male  Fern n\,  xxx. 

Chloroform Tl\  v. 

Syr.  Acacia 3  j. 

Mix.  After  a  saline  and  fasting  as  before  directed,  take 
the  above  at  one  dose,  preferably  in  the  morning.  A  half 
glass  of  milk  should  be  taken  immediately  afterward.  After 
two  hours  take  a  brisk  cathartic,  preferably  castor  oil. 


The  following  formula  combines  three  of  the  most 
prominent  remedies  for  the  removal  of  tape  worms  and 
deserves  mention. 

1^     Ethereal  Ext.  Pomegranate. 

Ethereal  Ext.  Male  Fern aa  gr.  vii j . 

Kousoo  Flowers,  Powd 3  v. 

Honey 3  v. 

Mix.     Divide  this  quantity  into  three  doses  and  take 


tape;   worms.  281 

one  dose  every  fifteen  minutes  until  three  are  taken.  The 
usual  fasting  rules  are  to  be  observed.  Two  hours  after  the 
last  dose,  follow  with  two  ounces  or  more  of  castor  oil. 


Salicylic  Acid  has  been  highly  spoken  of  as  a  remedy 
for  the  removal  of  tape  worms,  although  it  is  not  generally 
used  by  the  most  successful  practitioners  in  this  line.  This 
may  be  due  to  its  not  being  generally  known.  Dr.  Carnet, 
of  Connecticut,  claims  to  obtain  excellent  results  from  its  use. 
He  allows,  the  patient  to  eat  as  usual  and  gives  eight  grains 
of  salicylic  acid  every  hour  until  forty  grains  are  taken. 
After  the  last  dose  a  laxative  dose  of  castor  oil  is  given. 
The  worms  are  said  to  pass  alive  and  are  usually  passed 
entirely.    So  common  and  cheap  a  remedy  deserves  a  trial. 


282  ALOPECIA. 


ALOPECIA. 

Baldness  may  be  considered  physiological  when  it  occurs 
in  persons  well  advanced  in  years,  but  when  young  or  middle- 
aged  persons  are  thus  affected  it  may  well  be  termed  an 
abnormal  condition. 

The  etiology  of  baldness  is  not  by  any  means  clear. 
Trophic  disturbances  of  the  nervous  supply  of  the  occipito- 
frontalis  muscle  have  been  declared  to  be  the  cause,  but  this 
is  so  vague  that  it  is  equivalent  to  acknowledging  ignorance 
in  the  matter.  The  exclusion  of  light  and  air  due  to  continual 
wearing  of  the  hat  has  been  offered  as  a  possible  cause,  but 
the  large  majority  of  policemen,  coachmen  and  men 
employed  out-doors  and  who  wear  head  coverings  as  many 
hours  in  twenty-four  as  any  one,  have  an  average  supply  of 
hair. 

A  popular  belief  is  that  mental  labor,  continual  anxiety 
or  occupations  requiring  acuteness  of  vision  have  some  influ- 
ence in  connection  with  the  loss  of  hair,  but  a  large  percent- 
age of  teachers,  musicians,  bankers  and  literary  workers 
have  no  use  for  hair  restorers.  The  wearing  of  the  ordinary 
stiff  hat,  which  fits  the  head  closely  and  possibly  interferes 
with  the  proper  blood  supply  of  the  scalp  is  perhaps  a  factor 
in  those  who  become  bald,  or  possibly  in  those  who  have  a 
predisposition  to  baldness  through  heredity  or  otherwise,  but 
it  can  scarcely  be  termed  a  cause  per  se.  The  strongest  argu- 
ment in  its  favor  is  that  so  very  few  women  become  bald. 
Unless  lost  through  fever  or  some  systemic  disease,  there  is 
scarcely  a  woman  under  fifty  years  of  age,  who  has  not  the 
usual  quantity  of  hair.  The  parasite  theory  is  perhaps  the 
one  which  finds  most  favor,  probably  for  the  reason  that  it 
offers    an    explanation    which    cannot    well    be    disproved. 


ALOPECIA.  283 

Taking  it  as  a  premise  that  when  baldness  begins  under 
forty,  or  particularly  when  persons  twenty  or  thirty  years  of 
age  become  affected,  it  is  abnormal,  the  conclusion  must  be 
that  proper  treatment  will  frequently  benefit ;  either  in  arrest- 
ing the  loss  or  restoring  the  hair.  Prof.  Lassar  has  had  good 
success  with  the  treatment  which  follows,  as  have  also  others 
who  have  used  it.  Dr.  Bernheim,  of  this  city,  a  former  stu- 
dent of  Prof.  Lassar's,  has  obtained  beneficial  results  in  about 
a  dozen  cases.  The  treatment  must  be  patiently  persisted  in, 
diligently  applied  and  results  not  expected  too  early. 

Prof.  Lassar's  Treatment. 

First,  the  scalp  should  be  shampooed  every  day  for  eight 
weeks,  and  after  that,  every  other  day,  or  three  times  a  week, 
for  eight  weeks  more,  with  tar  soap,  made  by  adding  40 
parts  of  birchwood,  or  preferably  beechwood  tar,  to  60  parts 
of  soap  mixture.  Ordinary  tar  soap  is  too  weak  to  be  effect- 
ive. The  shampooing  must  be  done  thoroughly,  for  not  less 
than  ten  minutes,  after  which  the  soap  should  be  washed  off 
first  with  warm  water,  gradually  coming  to  cool  or  even  cold 
water.  The  hair  and  scalp  should  then  be  dried  by  patting  it 
with  a  cloth  or  tissue  paper.  The  scalp  should  next  be 
rubbed  with  the  following: 

I£      Mercuric  Chloride,  Corros gr.  xv. 

Glycerine, 

Cologne  Spts aa  fl.  §  iij. 

Water    fl.  %  x. 

Mix. 

Apply  to  scalp  with  soft  woolen  cloth  and  rub  for  five 
minutes.  After  this  rub  the  skin  dry  for  another  five  minutes 
with  a  solution  of 

I£     Beta  Napthol  gr.  xv. 

Absolute  Alcohol fl.  g  vij. 

Mix. 


284  ALOPECIA. 

After  this,  use  as  freely  as  possible,  a  hair  oil  as  follows  : 

I£     Acid   Salicylic    gr.  xxx. 

Tr.  Benzoin  3  j. 

Neatsfoot   Oil    fl.  5  iijss. 

Mix. 

Sig.  Rub  generous  portions  of  the  oil  into  the  scalp  for 
five  minutes. 

The  idea  of  this  procedure  is  to  remove,  by  means  of  the 
soap,  all  dirt,  dust,  etc.  The  mercuric  solution  is  readily 
taken  up  by  the  hair  follicles  and  seems  to  have  a  special 
tendency  to  stimulate  the  growth  of  hair.  The  napthol  alco- 
hol dries,  removes  fatty  substances  and  disinfects  the  scalp 
and  prepares  the  pores  for  the  absorption  of  the  hair  oil. 
Neatsfoot  oil  is  recommended  as  it  seems  to  be  better 
absorbed  and  assimilated  than  a  vegetable  oil.  Lanolin  might 
also  be  used. 

This  treatment  is  equally  effective  in  alopecia  areata,  and 
in  all  cases,  where  the  process  of  destruction  has  not  gone  too 
far,  certainly  will  stop  the  hair  from  falling  out,  so  that  the 
hair  still  in  possession  will  at  least  be  retained  . 

Treatment  by  Lactic  Acid. 

In  giving  the  following  treatment  as  a  remedy  for  pre- 
mature baldness,  I  shall  quote  it  as  written  by  a  physician 
whose  experience  it  narrates. 

"During  my  college  days  I  was  severely  troubled  with 
headaches,  the  pain  being  mostly  on  the  top  of  my  head ;  from 
that  time  on  my  head  became  dry  and  full  of  dandruff,  and 
my  hair  came  out  until  I  was  very  bald.  For  five  years  I  had 
my  head  shaved  twice  a  week,  but  no  favorable  results  came 
about,  and  I  gave  it  up.  I  then  tried  crude  petroleum  and 
thorough  massage  to  the  scalp  every  day  for  more  than  a 
vear,  with  negative  results.  Since  then  I  have  used  a  dozen 
remedies,  but  to  no  good  effect. 


ALOPECIA.  285 

"About  a  year  ago  I  hit  upon  an  application  in  which  I 
had  but  little  faith,  though  I  used  it  two  or  three  times  a 
month.  Now  I  have  hair  enough  to  comb  and  part  it  as  of 
yore. 

"There  is  still  a  patch  upon  the  extreme  top  of  my  head 
that  is  covered  with  very  fine  hairs,  yet  this  patch  is  steadily 
growing  smaller. 

"The  remedy  that  has  done  the  work  consists  of  a 
twenty-five  per  cent,  solution  of. lactic  acid  in  water.  Rub 
this  into  the  scalp  every  day  until  it  causes  pustulation.  Then 
it  is  to  be  left  off  until  the  pustules  disappear.  Then  it  is  to 
be  used  again  in  the  same  manner.  After  the  hair  began 
to  grow  I  omitted  the  pustulating  remedy  and  used 

B     Lactic  Acid    fl.  §  j. 

Quinine   Sulphate    gr.  xx. 

Glycerine    fl.  §  ss. 

Water   q.  s.  ad.  fl.  5  iv. 

Perfume  to  suit. 

"Mix  by  putting  the  quinine  into  the  acid,  making  a  clear 
solution,  before  adding  the  glycerine  and  water.  Apply  this 
to  the  hair  as  an  ordinary  dressing  every  day.  While  in  the 
last  formula  the  percentage  of  lactic  acid  is  the  same  as  in  the 
former,  the  addition  of  the  quinine  and  glycerine  prevents 
the  extreme  irritation  of  the  scalp.  This  irritation,  I  believe, 
is  of  great  importance  at  the  beginning  of  the  treatment. 
This  remedy  does  even  more  than  grow  hair.  It  restored  the 
original  dark  color  of  my  hair  after  I  was  as  gray  as  a 
badger.     (I  have  passed  the  50  mark). 

"Don't  expect  results  in  a  month.  Try  it  a  year  before 
you  register  any  complaints." 


286  ENURESIS. 


ENURESIS. 


The  successful  treatment  of  enuresis,  especially  the  noc- 
turnal form,  is  often  attended  with  considerable  difficulty. 
In  the  majority  of  cases,  no  pathological  changes  can  be 
determined,  and  when  present,  they  do  not  as  a  rule  indicate 
the  curative  course  of  treatment. 

Bed-wetting  is  said  to  be  due  to  several  causes :  Irrita- 
bility of  the  bladder,  relaxation  of  the  sphincter  muscle  of 
the  bladder,  or  spasmodic  contraction  of  the  bladder.  Treat- 
ment directed  toward  the  relief  of  either  or  all  of  these  con- 
ditions with  the  remedies  they  would  suggest,  is  usually 
unproductive  of  good  results.  Occasionally  a  cure  will  be 
effected,  but  the  average  results  are  not  such  as  will  earn 
for  the  practitioner  a  reputation  for  special  skill  in  the  treat- 
ment of  the  condition. 

The  drug  that  will  give  the  best  results  in  a  large  per- 
centage of  cases,  disregarding  the  cause,  which  can  but  sel- 
dom be  correctly  determined,  is  Rhus  Aromatica,  the  Sweet 
Sumach  that  grows  throughout  the  Eastern  section  of  this 
country.    The  bark  of  the  root  is  the  part  used. 

The  dose  of  the  fluid  extract  is  one  drachm  or  less,  and 
of  the  solid  extract  up  to  ten  grains,  yet  full  doses  are  seldom 
necessar)',  nor  conducive  to  the  best  results. 

As  the  patients  are  usually  children,  the  doses  need  not 
exceed  ten  to  fifteen  minims  of  the  fluid  extract,  or  two 
grains  of  the  solid. 

In  combination  with  nux  vomica  its  selective  action  in 
this  condition  is  strengthened  and  results  more  satisfactory. 

As  a  dose  for  a  child  four  to  eight  years  old,  the  follow- 
ing formula  will  be  eligible : 

M     Ext.  Rhus  Aromatica gr.  ij. 

Ext.  Nux  Vomica gr.   %. 

Mix.     Ft.     Tablet  No.  i. 


HYDROCELE.  287 

Sig.  Give  one  such  after  supper  and  at  bedtime.  If  no 
improvement  is  noticed  in  a  week,  increase  the  number  of 
lablets  to  four  a  day,  giving  them  in  addition  in  the  morning 
and  at  noon.  Continue  treatment  one  month  after  an  appar- 
ent cure. 

Little  or  no  fluids  should  be  taken  after  6  P.  M.,  and 
during  the  day  an  effort  should  be  made  to  retain  the  urine 
as  long  as  possible  without  inconvenience  or  injury. 

In  old  men,  when  prostatic  troubles  cause  urinary  diffi- 
culties, these  tablets,  giving  six  to  ten  a  day,  in  combination 
with  fluid  extract  of  Pichi,  in  drachm  doses,  four  times  a 
day,  will  be  found  an  excellent  treatment. 


hydrocele. 

The  Radical  Cure. 

The  radical  cure  of  hydrocele  should  not  be  performed 
in  persons  over  sixty  years  of  age,  and  never  when  the 
patient  is  subject  to  dropsical  symptoms. 

In  younger  patients,  when  free  from  such  complications, 
this  treatment  should  be  employed,  as  a  temporary  incon- 
venience will  render  the  patient  free  from  annoyance  for  the 
rest  of  his  life. 

The  operation  should  be  performed  in  this  manner : 

The  sac  is  punctured  in  the  usual  manner  and  about 
one-half  of  the  fluid  is  withdrawn.  The  canula  is  then  ele- 
vated and  two  drachms  of  a  saturated  solution  of  bichloride 
of  mercury  in  glycerine  is  injected  through  it  and  mixed 
with  the  remainder  of  the  fluid.  After  one  minute,  the  whole 
of  the  fluid  is  withdrawn,  special  attention  being  directed 
toward  its  entire  removal.  Very  little  pain  is  experienced 
and  the  patient  can  usually  move  about  immediately  after 
the  operation.  Patient  need  not  be  confined  to  bed,  but  for  a 
few  days  should  remain  quiet,  and  in  a  week  he  will  be  well. 


288  HYDROCELE. 

The  bichloride  acts  as  its  own  antiseptic,  yet  instruments 
should  be  perfectly  clean. 

Note: — Do  not  use  equal  parts  of  a  saturated  solution 
of  bichloride  of  mercury,  in  water,  and  glycerine,  but  a  sat- 
urated solution  of  bichloride  in  glycerine. 

ANOTHER  METHOD. 

After  withdrawing  all  the  fluid  in  the  sac,  inject  into  it  a 
mixture  of  Lloyd's  Specific  Thuja  and  glycerine,  one  half 
drachm  of  the  former  to  one  and  one-half  drachm 
of  the  latter.  This  quantity  is  used  in  hydroceles 
from  which  one  pint  of  fluid  has  been  removed.  When  larger 
or  smaller,  use  proportionate  quantities  of  this  compound. 
After  injection,  the  scrotum  must  be  manipulated  so  as  to 
bring  the  fluid  into  contact  with  the  entire  sac.  There  will 
be  swelling  and  inflammation  for  a  few  days,  but  little  pain, 
and  in  four  or  five  days  the  patient  will  be  well. 

Prof.  Wyeth,  of  N.  Y.,  used  thirty  minims  of  pure  car- 
bolic acid,  injected  into  the  sac,  after  all  the  fluid  had  been 
withdrawn.  The  advantages  claimed  for  carbolic  acid  are 
certainty  of  action,  freedom  from  pain  and  the  mild  degree 
of  inflammation  produced.  In  fifty  cases  treated  by  Prof. 
Wyeth,  only  two  were  not  cured  by  the  first  injection. 

Considering  the  effects  of  carbolic  acid,  as  mentioned  in 
another  part  of  this  volume,  its  employment  in  hydrocele 
is  in  line  with  modern  practice.  Its  anesthetic  action  in  burns 
and  open  wounds  can  easily  be  demonstrated  and  when  intro- 
duced into  the  scrotum  its  action  is  similar.  To  insure  per- 
fect results  the  fluid  should  all  be  withdrawn,  so  that  the  acid 
will  not  be  diluted,  as  diluted  acid  is  painful  and  is  absorbed. 

Tr.  Iodine,  so  often  recommended  for  the  radical  cure 
of  hydrocele,  is  an  extremely  irritating  and  painful  agent, 
and  is  not  used  to  any  great  extent  at  this  time.  In  as  much 
as  other  remedies  can  be  employed  which  are  in  all  respects 
preferable  to  iodine,  there  remains  but  little  justification  for 
its  use. 


VARICOCELE.  289 

VARICOCELE. 

Its  Treatment. 

The  following  modification  of  the  well  known  ligation 
treatment  for  varicocele  is  a  decided  improvement  over  it, 
and  can  be  relied  upon  in  every  particular;  it  is  curative, 
safe,  not  painful  and  the  operation  requires  but  little  time  for 
its  performance. 

With  the  patient  standing,  so  as  to  distend  the  veins, 
crowd  them  to  the  scrotal  wall  and  pass  a  needle  armed 
with  an  elastic  ligature,  through  both  scrotal  walls,  behind 
the  vein,  excluding  the  vas  deferens  and  cord.  The  vas 
deferens  can  be  readily  distinguished  by  its  tough  cord-like 
touch.  It  is  found  back  of  the  cord.  When  this  has  been 
done,  let  the  patient  lie  down  and  by  proper  manipulation, 
empty  the  veins  of  all  the  blood,  and  tie,  including  the  vein 
and  skin  in  the  loop,  tight  enough  so  that  the  ligature  will 
cut  its  way  out.    Dress  with  a  simple  antiseptic  dressing. 

To  carry  the  elastic  ligature  through,  the  best  method 
is  to  thread  the  needle  with  a  silk  ligature  which  has  attached 
to  it  the  rubber  ligature,  and  pull  it  through  after  the  needle 
has  been  removed.  In  order  that  the  rubber  ligature  may  not 
pass  through  entirely  thus  making  another  passage  of  the 
needle  necessary,  attach  an  artery  forceps  to  the  end  of  it. 
When  the  ligature  is  in  place,  tighten  it  by  passing  both  ends 
of  the  ligature  through  a  tongue-tie  and  when  tight  enough 
keep  in  place  by  grasping  the  ligature  with  the  artery  forceps. 
Pass  a  silk  ligature  between  the  tongue-tie  and  artery  forceps 
and  tie  tight.  The  rubber  ligature  is  not  tied  into  a  knot,  but 
is  held  together  by  a  silk  ligature.  Use  only  the  very  best 
quality  of  rubber  ligature,  and  see  that  it  is  perfect  before 
using.  The  skin  and  vein  will  be  cut  through  in  the  course 
of  a  week  without  inconvenience  to  the  patient.  There  is  no 
sloughing  and  barely  forms  a  scab.  Enclose  as  little  skin  in 
the  ligature  as  possible.  The  operation  is  extremely  simple, 
yet  highly  satisfactory. 


29O  URETHRAL    STRICTURE. 


URETHRAL  STRICTURE. 


Treatment  by  the  Solvent  Method. 

By  reason  of  the  persistent  advertising  of  this  method 
by  the  irregular  specialists,  considerable  interest  has  been 
aroused  and  many  inquiries  have  been  received  concerning  it. 

The  idea  of  this  treatment  has  evidently  been  derived 
from  the  knowledge  that  diphtheritic  and  other  false  mem- 
branes are  dissolved  and  destroyed  by  the  digestive  ferments. 

The  passage  of  casts  from  the  urethra,  sometimes  of 
considerable  size  and  formation,  after  treatment  by  this 
method,  would  seem  to  warrant  hope  of  benefit  from  its  use- 

The  following  formula  may  be  used  for  this  purpose : 

It      Ext.  Hyoscyamus   gr.  ss. 

Ext.  Calendula gr.  j. 

Carica  papaya   gr.  j. 

Powd.   Elm    gr.  v. 

Mix.  Form  into  one  bougie  and  place  into  the  con- 
stricted portion  of  the  urethra. 

Prior  to  the  introduction  of  the  bougie  the  stricture 
should  be  dilated.  If  difficulty  be  experienced  in  the  intro- 
duction of  the  sound,  the  injection  of  a  few  drops  of  fluid 
extract  of  hyoscyamus  will  cause  relaxation  and  facilitate  its 
passage.    Use  a  bougie  each  night. 

The  following  formula  is  offered  for  the  same  purpose, 
also  for  acute  or  chronic  gonorrhoea.  This  ointment  is 
penetrating,  owing  to  the  alboline ;  germicidal,  owing  to  the 
mercury  and  silver ;  a  solvent  for  the  fibrous  exudate,  due  to 
the  pepsin  and  caroid. 


URETHRAL   STRICTURE.  2yl 

The  formula  : 

J£     Yellow  Oxide  of  Mercury gr.  xx. 

Oxide  of  Silver 5  ij. 

Oleic  Acid    o  j. 

Powd.  Scale  Pepsin 5  iv. 

Powd.  Caroid    o  iv. 

Alboline    %  ij  • 

Lanolin o  ij- 

Water   §  ij . 

Mix  as  follows :  Dissolve  the  oxides  of  mercury  and 
silver  in  the  oleic  acid  and  albolene.  To  do  this  it  is  neces- 
sary to  triturate  the  oxides  in  a  large  mortar  dry,  then  add 
oleic  acid,  and  continue  the  trituration  till  the  mass  begins  to 
stiffen ;  then  add  the  albolene  quickly,  and  the  trituration 
must  be  continued  till  a  uniform  paste  is  obtained.  Then  add 
the  lanolin,  and  rub  it  well  into  the  mixture.  Finally,  having 
dissolved  the  pepsin  and  caroid  in  the  water,  and  filtered  it 
through  a  funnel  lightly  plugged  with  absorbent  cotton,  (this 
is  necessary,  as  the  caroid  has  grit  in  it),  add  this  aqueous 
solution  to  the  salve  in  the  mortar,  and  triturate  the  whole 
till  it  is  a  uniform,  creamy  paste.  These  details  are  impor- 
tant, and  any  departure  will  result  in  a  lumpy,  uneven  mass, 
that  is  not  only  inelegant,  but  much  inferior  therapeutically. 
By  means  of  an  applicator,  introduce  into  the  urethra,  at 
the  point  desired,  half  to  one  drachm  of  the  remedy.  For 
stricture,  an  application  twice  or  three  times  a  week  will  be 
sufficient,  while  for  acute  and  chronic  gonorrhoea,  applica- 
tions should  be  made  night  and  morning. 

Dr.  T.  W.  Williams  informs  me  that  he  has  often 
observed  the  passage  of  casts  from  the  urethra,  following- 
applications  of  citrine  ointment  in  the  treatment  of  prostatic 
disease,  described  in  the  latter  portion  of  this  work. 

The  applications  can  be  best  made  with  the  Urethral 
Applicateur  described  in  Dr.  Williams'  article  just  men- 
tioned. 


2Q2  MEDICAL    MELANGE. 


MEDICAL  MELANGE. 


Practical  and  Helpful. 

It  is  often  the  little  things  that  cause  us  the  most  worry 
and  anxiety.  Hundreds  of  good  practical  suggestions  are 
yearly  published  in  medical  journals,  but  are  frequently  lost 
sight  of  in  the  mad  scramble  to  learn  the  latest  development 
in  Prof.  Scientific' s  pathological  researches ;  to  become 
acquainted  with  the  latest  classification  of  microbes,  or  indeed 
to  be  the  first  in  any  locality  to  experiment  on  some  unfor- 
tunate individual  with  the  latest  product  of  some  German 
paint  or  dye  factory.  A  well  developed  and  misbehaving 
corn  on  the  last  quarter  of  an  inch  of  a  man's  anatomy  often 
causes  him  more  annoyance  and  genuine  discomfort  than  a 
double  complete  inguinal  hernia,  and  a  wart  or  mole  on  the 
face  of  a  society  belle,  will,  if  removed,  be  responsible  for 
more  recommendations  of  your  skill  than  if  you  had  repaired 
the  lacerated  cervix  with  which  she  suffers  in  the  privacy  of 
her  home. 


THE  SOLAR  CAUTERY. 

The  rays  of  the  sun  when  properly  focused  are  known 
to  be  irritant  and  caustic,  destroying  tissue  and  igniting 
inflammable  material. 

As  a  therapeutic  agent  the  solar  cautery  is  not  generally 
employed,  and  yet  some  physicians,  especially  dermatologists 
and  cosmetic  specialists  use  it  quite  extensively  and  to  good 
effect.  For  the  purpose  of  focusing  the  rays  properly  at  a 
convenient  distance,  a  lens  of  ten  to  twelve  dioptric  power  is 
preferable.  Several  lenses  should  be  procured,  each  of  dif- 
ferent power.  Some  lenses  will  not  focus  as  well  as  others, 
and  care  should  be  used  in  selecting  them.     For  some  reason 


MEDICAL   MELANGE.  293 

or  other  a  blue  glass,  medium  tint,  seems  to  act  better  when  a 
great  deal  of  tissue  is  to  be  destroyed.  Some  claim  that  the 
blue  light  is  antiseptic  and  kills  parasites  and  microbes 
quicker  than  a  colorless  lens.  Small  growths  of  the  skin, 
such  as  warts,  moles  or  a  capillary  aneurism  can  be  removed 
by  one  treatment  and  without  much  pain.  The  pain  will  be 
proportionate  to  the  tissue  destroyed.  To  prevent  pain  a 
local  anesthetic  is  employed,  usually  cocaine  in  four  per 
cent,  solution.  Eucaine,  chloretone  or  strong  carbolic  acid 
may  also  be  used.  The  anesthetic  is  applied  to  the  growth  to 
be  removed  and  the  growth  covered  with  a  piece  of  asbestos 
cloth  with  a  small  hole  in  the  centre,  just  large  enough  to 
allow  the  growth  to  be  treated  through  the  hole  without 
injuring  the  surrounding  parts.  Paper  may  be  used  for  this 
purpose,  but  it  frequently  ignites  and  causes  annoyance  and 
delay.  After  an  application  of  a  few  seconds  more  anesthetic 
may  be  applied,  and  thus  repeated  until  the  treatment  is  com- 
pleted. Warts  are  usually  not  sensitive  until  the  deeper 
structures  are  reached,  and  small  warts  may  be  burnt  level 
with  the  skin  without  any  material  discomfort.  A  wart  will 
smoke  and  sizzle,  but  a  mole  will  not,  but  the  latter  will  form 
a  blister  and  the  application  must  be  continued  a  little  beyond 
forming  a  blister.  If  one  treatment  is  not  sufficient,  as  can 
be  seen  after  a  week  or  ten  days,  the  treatment  must  be 
repeated.  Continue  the  application  until  you  have  burnt  level 
with  the  skin  when  treating  warts ;  and  a  trifle  longer  than  to 
raise  a  blister  when  treating  moles.  If  the  patient  complains  of 
pain  continue  as  long  as  he  keeps  still,  then  apply  more  anes- 
thetic and  continue.  If  the  burn  is  not  too  deep  there  will  be 
no  scar  following  this  treatment.  In  Epithelial  cancers,  if 
seen  early,  this  treatment  is  strongly  recommended  and  will 
frequently  arrest  the  disease.  Burn  deep,  without  regard  for 
the  scar  that  will  take  its  place.  This  disease  is  not  treated 
for  its  cosmetic  effect.  Corns  can  easily  be  cured  by  the  solar 
cautery.  Pare  away  the  calloused  skin  and  make  several 
strong  applications.  A  little  soreness  follows  but  it  kills  the 
corn.     Repeat  until  entirely  relieved. 


2«J4  MEDICAL    MELANGE. 

WARTS  may  also  be  removed  by  the  following 
method,  which  is  more  applicable  when  these  excrescences 
are  multiple  or  confluent. 

R     Sulphur  Sub   '.        5  v. 

Cone.   Acetic  Acid fl.  3  iiss. 

Glycerine fl.  5  ij. 

Mix.  This  paste  is  applied  to  the  warts  either  with  a 
brush  or  spread  over  them  on  small  pieces  of  linen.  This 
is  done  at  night  and  washed  off  in  the  morning.  Repeat  the 
application  thus  for  several  days.  Under  this  treatment  warts 
become  blue,  shrivel  up  and  drop  off. 


AN  EXTERNAL  REMEDY  FOR  RESPIRATORY 
DISEASES. 

One  of  the  oldest  remedies  in  use  to-day  is  the  one  of 
which  the  formula  is  here  given.  It  is  of  doubtful  origin, 
but  highly  spoken  of  by  such  eminent  practitioners  as  Aitkin, 
Stokes  and  Graves,  to  say  nothing  of  the  lesser  lights  who 
are  using  it  in  their  daily  routine  of  work  with  excellent 
results. 

T£      Spts.  Turpentine   fl.  §  iij. 

Acid  Acetic   fl.  5  iv. 

Yolk  of  Egg One. 

Rose  Water    fl.  3  iiss. 

Oil  of  "Lemon fl.  3  j. 

Mix.  First  rub  the  yolk  of  egg,  the  water  and  the 
acetic  acid  together  in  a  mortar  until  an  intimate  mixture 
results,  then  add  the  spirits  of  turpentine  and  shake  vigor- 
ously; lastly  add  the  oil  of  lemon.  In  bronchitis,  asthma, 
congestion  of  the  lungs,  pleurisy  and  even  in  phthisis  this 
remedy  cannot  be  too  strongly  recommended.  The  chest  and 
neck  should  be  sponged  with  it  morning  and  evening.  It  not 
only  acts  beneficially  on  account  of  its  counter  irritant  action, 
but  the  remedv  is  absorbed  and  acts  as  a  direct  stimulus.     It 


MEDICAL    MELANGE-  295 

produces  more  or  less  redness  of  the  surface,  but  its  beneficial 
action  does  not  seem  to  depend  on  the  degree  of  redness  pro- 
duced, hence  my  conclusions  that  it  is  absorbed.  Its  action 
on  the  kidneys,  by  which  the  flow  of  urine  is  increased,  is 
quite  marked;  the  noticeable  odor  of  turpentine  in  the  urine 
being  an  evidence  of  this  fact.  In  simple  swelling  of  the 
tonsils  and  inflammation  of  the  throat,  so  often  met  with  in 
children,  it  should  be  applied  to  the  neck  and  a  flannel  band- 
age applied.  In  bronchitis  and  congestion,  the  entire  neck 
and  chest  should  be  rubbed  with  it.  In  asthma,  its  daily 
use,  when  paroxysms  are  frequent,  is  indicated,  and  during 
the  paroxysms  especially  an  application  should  be  made.  The 
great  relief  and  entire  dissipation  of  the  paroxysm  which  I 
have  so  often  seen  follow  an  application  of  this  remedy,  is 
sufficient  to  stamp  it  as  one  of  our  best.  In  the  dyspnoea 
acompanying  pneumonia,  pleurisy  and  phthisis  its  application 
will  almost  invariably  afford  relief.  Other  treatment  is  not 
interfered  with  and  can  be  piven  as  indicated. 


USES  OF  CARBOLIC  ACID. 

Carbolic  acid,  besides  being  one  of  our  best  antiseptics, 
and  in  many  cases  to  be  preferred  to  bichloride  of  mercury, , 
has  other  uses  which  make  it  worthy  of  special  mention.     It 
is  the  only  drug  that  combines  cauterant,  anesthetic,  antisep- 
tic and  antiphlogistic  properties. 

The  most  astonishing  use  of  carbolic  acid*  is  its  applica- 
tion, pure  and  undiluted,  to  open  surfaces,  abscess  cavities, 
freshly  exposed  tissues  and  burns.  When  carbolic  acid  is 
thus  applied  pure  and  undiluted,  it  is  a  perfectly  harmless 
agent.  Its  application  to  burns,  where  the  skin  has  been 
destroyed  and  the  tissues  injured,  and  the  victim  suffering 
intense  pain,  will  almost  immediately  cause  the  pain  to  cease. 

It  should  be  applied  with  a  feather  or  camel's  hair  brush. 
If  thus  applied  there  is  absolutely  no  absorption,  as  the  acid 


296  MEDICAI,   MELANGE. 

forms  with  the  serum  of  the  blood  an  impervious  albuminate, 
which  renders  absorption  impossible.  This  covering  also 
excludes  the  air  and  acts  as  an  anesthetic  to  the  injured  nerve 
filaments.  If  the  covering  thus  formed  should  become  dis- 
turbed by  the  removal  of  bandages,  another  application 
should  be  made.  This  treatment  was  originated  as  far  as  can 
be  ascertained  by  Dr.  Ben.  H.  Brodnax,  of  Brodnax,  La.,  and 
was  favorably  commented  upon  by  Dr.  O.  H.  Allis,  of  Phila- 
delphia, Pa.,  who  also  read  a  paper  on  the  subject  before  the 
Philadelphia  Medical  Society,  extracts  of  which  were  later 
published  by  the  Philadelphia  Polyclinic.  Dr.  Allis  says :  "It 
will  strike  many  of  you  with  astonishment  when  I  say  that 
it  would  be  safer  to  pour  a  gallon  of  pure  carbolic  acid  into  a 
purulent  thoracic  cavity  than  to  pour  into  it  a  gallon  of  water 
into  which  a  single  ounce  of  carbolic  acid  had  been  placed.  I 
will  go  further  and  say  that  excess  of  the  strong  acid  in  a 
cavity,  such  as  an  abscess  cavity,  or  upon  exposed  tissues,  as 
a  burn  or  a  fresh  wound,  does  no  harm,  while  excess  of  a 
dilute  solution,  if  left  in  a  cavity  or  used  over  an  extensive 
raw  surface,  will  be  promptly  followed  by  dangerous,  if  not 
fatal  toxic  effects."  It  requires  some  courage  to  apply  strong 
carbolic  acid  to  a  raw,  glaring,  quivering  wound,  but  prompt 
and  excellent  results  will  immediately  follow  the  application. 
It  should  be  applied  thoroughly,  all  over  the  wounded  sur- 
face, up  to  the  very  margin  of  the  uninjured  portion,  and  a 
light  cotton  dressing  applied.  No  other  local  treatment  is 
required  in  these  cases,  and  nothing  better  nor  safer  can  be 
obtained.  The  acid  to  be  used  must  be  the  full  strength,  not 
the  acid  to  which  five  or  ten  per  cent,  of  glycerine  has  been 
added  to  maintain  solubility,  but  the  liquid  resulting  from 
heating  the  crystals. 

For  the  purpose  of  liquefying  carbolic  acid,  it  should 
never  be  heated  in  any  other  manner  than  in  a  water  bath, 
with  the  cork  removed.  The  vapor  is  inflammable  and  may 
explode  if  brought  into  contact  with  the  naked  flame.  After 
being  liquefied  it  will  remain  so,  if  kept  at  a  temperature 
of  1050  F. 


MEDICAL  MELANGE.  297 

TO  ABORT  BOILS,  carbolic  acid  should  be  injected 
into  the  centre  of  the  boil,  two  or  three  drops  being  sufficient 
to  do  the  work.  Use  the  pure  acid  fearlessly.  There  is  no 
pain  and  no  danger. 

For  hypodermatic  or  deep  injection,  it  is  impossible  to 
prevent  crystalization  in  the  syringe  and  needle,  unless  the 
instruments  are  kept  warm.  After  filling  a  syringe,  place 
it  into  hot  water  a  few  minutes,  and  inject  quickly.  A  good 
syringe  will  not  admit  water,  even  if  immersed. 

LANCING  A  FELON  can  be  painlessly  accomplished 
by  dipping  the  finger  into  a  twenty  per  cent,  solution  of  car- 
bolic acid  and  allowing  it  to  remain  there  for  a  few  minutes. 
Wait  half  an  hour  before  lancing.    No  pain  will  be  felt. 

ANTIDOTES.  The  best  antidote  to  carbolic  acid  is 
Alcohol.  The  action  of  carbolic  acid  may  be  arrested  at  any 
stage  by  the  application  of  alcohol.  If  accidentally  swal- 
lowed, alcohol  is  the  remedy.  Glycerine  also  partakes  of  this 
property  to  some  extent,  but  is  not  as  active  as  alcohol. 
Acetic  acid  is  even  better  than  glycerine ;  it  will  destroy  the 
odor  of  carbolic  acid,  and  if  applied  to  the  white  surface 
caused  by  its  contact  with  the  skin,  will,  by  gently  rubbing 
the  part,  restore  its  natural  color  in  a  short  time. 

Carbolic  acid  is  also  a  valuable  addition  to  cocaine  solu- 
tion intended  for  hypodermatic  injection.  It  renders  absorp- 
tion less  liable,  aids  anesthesia  and  preserves  the  solution. 
The  usual  proportion  in  solutions  of  this  kind  is  eight  drops 
to  the  ounce. 


298  MEDICAL   MELANGE. 

FLEXIBLE  SPLINTS. 

The  flexible  splint,  if  well  made  and  of  good  material, 
has  much  to  commend  it.  It  conforms  perfectly  to  the  part 
to  which  it  is  applied,  is  comfortable  to  the  patient,  and  by 
is  rigidity  assists  in  perfect  union  being  obtained.  The  fol- 
lowing formulae  are  the  best  obtainable  for  the  purpose : 

J^     Powd.  Gum  Shellac J  xvj. 

95   %  Alcohol fl.  5  xxiv. 

Sodium  Biborate. 

Castor   Oil    aa        3  ij . 

Mix.  Dissolve  the  shellac  in  the  alcohol  and  add  the 
other  ingredients  and  shake  well. 

Old  woolen  cloth  is  the  best  material  for  making  splints. 
Apply  the  solution  to  one  side  with  a  paint  brush  and  dry 
before  a  hot  fire.  Then  apply  a  second  coat  to  the  same  side 
and  dry  as  at  first.  Take  two  pieces  thus  prepared  and  place 
the  two  coated  sides  together  and  unite  them  firmly  by  press- 
ing them  with  a  hot  iron.  When  ready  to  use  a  splint  thus 
prepared,  dip  it  in  hot  water  or  heat  before  a  fire  until  pliable. 
Shape  the  splint  by  holding  it  in  place  until  it  sets.  Line  it 
with  cotton  and  apply  it,  keeping  it  in  place  with  the  ordi- 
nary bandage.  The  same  splint  can  be  used  over  and  over 
again  until  too  much  soiled. 

A  SECRET  FORMULA. 

The  following  formula  was  sold  by  a  Western  physician 
for  four  dollars.    He  called  it  "Chydde's  Solution." 

J£     Liquor  Soda-silicate  fl.  3  xvj. 

Dextrine    %  x. 

Venice  Turpentine    %  j. 

Alcohol   fl.  §  iv. 

Acid  Boracic   5  j. 

Mix.    It  is  used  in  the  same  manner  as  the  other. 


MEDICAL    MELANGE.  299 

PAINLESS  TOOTH  EXTRACTION. 

Physicians  are  frequently  called  upon  to  extract  teeth 
for  the  relief  of  pain,  and  to  such  the  following  formula  will 
commend  itself.  If  properly  injected  there  is  really  but  little 
pain  experienced.  It  is  very  similar  in  appearance  and  odor 
to  a  well  known  proprietary  article  sold  to  dentists  at  $1.00 
per  ounce. 

I£      Cocaine  Muriate   gr.  xx. 

Ac.  Carbolic,  cryst gr.  xxiv. 

Gum  Camphor gr.  xxiv. 

Alcohol,  95  °/o q.  s.  ad.  5  j. 

Mix.  Inject  three  minims  of  this  mixture  deeply  into 
the  gum  on  the  inner  and  outer  side  of  the  tooth,  and  apply 
all  around  it  a  piece  of  cotton  wet  with  the  solution.  Allow 
it  to  remain  three  to  four  minutes,  incise  the  gum  freely  and 
extract.  Always  pull  outward  when  extracting  teeth,  no 
matter  in  what  direction  the  tooth  points. 
Another,  for  local  application : 

IJ      Oil  Gauitheria   fl.  3  ij. 

Chloral  Hydrate    o  ij. 

Chloroform. 

Sulphuric  Ether aa  fl.  3  j. 

Oil  Cloves fl.  3  iv. 

Alcohol   fl.  3  xij. 

Mix. 

Apply  by  means  of  cotton  saturated  with  the  solution. 
Allow  it  to  remain  five  minutes.  Protect  surrounding  tissues 
by  placing  dry  cotton  about  the  inner  and  outer  side  of  the 
tooth. 


CHLORAL— CAMPHOR. 

When  Chloral  Hydrate  and  Gum  Camphor  are  mixed  in 
equal  parts  and  triturated  in  a  mortar,  a  heavy,  oily  liquid 
results  which  is  a  veritable  cure-all.  A  pledget  of  cotton 
saturated  with  it  and  placed  in  the  cavity  of  a  decayed  tooth 
will    almost    immediatelv    relieve    the    pain    of    tooth-ache ; 


300  MEDICAL   MELANGE. 

applied  along  the  nerve  trunks  in  neuralgia  the  relief  is 
almost  immediate  and  quite  lasting;  painted  over  the  abdo- 
men, especially  in  the  region  of  the  ovaries,  it  relieves  the 
pain  of  dysmenorrhoea  and  ovarian  neuralgia.  By  the  addi- 
tion of  Carbolic  acid  its  value  is  increased  and  is  applicable 
to  many  other  diseased  conditions.  When  Carbolic  Acid  is 
added,  use  equal  parts  of  each;  Gum  Camphor,  Chloral 
Hydrate  and  Carbolic  Acid  crystals.  It  is  a  sterling  remedy 
for  all  external  sores  and  ulcers,  chancres  or  syphilitic  sores, 
suppurating  cavities,  or  to  stimulate  granulations  of  indolent 
ulcers.  It  may  be  diluted  one  half  to  one  third  and  used  in 
sore  throat  with  a  brush,  and  to  ulceration  of  the  cervix  or 
mucous  patches.  The  compound  containing  the  acid  is  less 
painful  but  even  without  it  the  mixture  is  not  severe.  For 
the  purpose  of  dilution  olive  oil  or  a  hydro-carbon  oil  should 
be  used. 


"Success  requires  not  something  new 
To  win  applause  and  recognition, 
But  doing  that  which  others  do, 
Beyond  their  range  of  competition." 


DRUGS    USED.  3QI 

DRUGS  USED. 

As  pure  and  reliable  drugs  are  of  necessity  essential  to 
success,  considerable  care  should  be  exercised  in  their  selec- 
tion. 

When  fluid  extracts  are  purchased,  original  packages 
should  be  secured  if  possible,  and  as  all  of  the  principal  phar- 
maceutical firms  supply  packages  of  as  low  as  four  ounces, 
there  is  little  excuse  for  using  drugs  of  unknown  or  uncer- 
tain quality. 

Tinctures  made  from  standardized  or  physiologically 
tested  extracts  are  entirely  reliable. 

Chemicals,  especially  those  of  a  delicate  or  unstable 
nature,  should  be  selected  with  due  regard  as  to  their  purity, 
and  deterioration  guarded  against.  Those  made  by  Merck, 
Mallinckrodt  or  other  reliable  chemists  are  to  be  preferred 
to  the  inferior  commercial  salts  often  found  in  the  shops. 

Carbolic  acid,  either  Mallinckrodt's  Gilt  Label,  or 
Merck's  Dry  Crystals,  is  fully  as  effective  and  reliable  as 
Calvert's  English  product,  and  much  less  expensive. 

Peroxide  of  Hydrogen  is  such  an  unstable  and  variable 
article  that  specimens  purchased  in  the  open  market  are  fre- 
quently devoid  of  any  cleansing  or  stimulating  properties,  or 
may  even  be  irritating  and  injurious. 

Marchand's  Hydrozone  and  Medicinal  Peroxide  of 
Hydrogen,  the  former  of  thirty  volumes  and  the  latter  of 
fifteen  volumes  strength,  are  superior  preparations  and  have 
given  me  better  results  than  any  similar  preparation. 


302  SECRET    SYSTEMS   EXPOSED. 


SECRET  SYSTEMS  EXPOSED. 

The  Medical  Profession  has  for  all  time  past  been  con- 
sidered somewhat  of  a  "pasture  green"  for  the  scheming 
individual  representing  a  company  who  had  a  "Secret  Sys- 
tem" for  sale.  Many  physicians  have  been  severely  imposed 
upon  by  this  smooth  tongued  gentry  and  have  been  induced 
to  pay  exorbitant  sums  for  the  "secret"  and  the  exclusive 
right  to  use  the  same  in  a  certain  limited  territory.  Many  of 
these  secret  systems  possess  merit,  and  it  is  not  on  the 
account  of  worthlessness  or  misrepresentation  that  objection 
to  this  method  of  doing  business  is  made,  but  on  account  of 
the  unreasonable  fees  which  are  asked  for  and  received,  being 
in  most  cases  prohibitive  and  practically  limiting  the  field  to 
the  few  whose  income  warranted  the  outlay,  and  which  there- 
fore was  already  above  the  average.  This  method  of  fur- 
nishing information  is  also  not  in  accord  with  the  broad  spirit 
of  the  medical  profession,  nor  with  the  liberality  which  char- 
acterized the  fathers  of  medicine  to  whom  we  are  all  greatly 
indebted.  While  a  great  deal  of  this  sort  of  business  was 
carried  on  by  personal  representation,  the  advertising  pages 
of  many  medical  journals  carried  advertisements  bringing 
secret  systems  of  this  class  to  the  notice  of  the  profession, 
instances  of  which  can  probably  be  recalled  by  anyone. 
Through  the  courtesy  of  a  number  of  professional  friends 
and  the  outlay  of  considerable  cash,  the  author  is  enabled 
to  place  before  the  profession  the  majority  of  the  better 
known  systems  of  this  kind.  That  they  possess  some  merit 
is  evident  from  their  composition,  whether  to  a  greater  or 
lesser  degree  than  many  of  the  more  familiar  combinations  of 
remedial  agents,  depends  perhaps  on  the  degree  of  skill  with" 
which  they  are  applied. 


SECRET   SYSTEMS   EXPOSED.  303 

If  their  introduction  here  will  assist  in  satisfying  a 
curiosity  known  to  exist  among  medical  men,  and  in  a  meas- 
ure lift  the  sombre  robe  that  clothes  some  of  the  secrets  and 
mysteries  connected  with  the  healing  art,  the  objects  for 
doing  so  will  have  been  accomplished. 


The  Triumph    System  of  Treating   Drug  and 
Other  Addictions. 

Several  years  ago  a  representative  of  this  concern 
located  in  Knoxville,  Tenn.,  canvassed  this  and  other  states 
in  the  interest  of  the  following  Secret  Systems  for  the  Treat- 
ment of  Drug  and  Other  Addictions,  which  was  sold  to  physi- 
cians at  figures  varying  from  $10.00  cash  to  $50.00  or  more 
in  installments  and  commissions. 

This  is  a  fair  specimen  of  what  is  sold  to  physicians 
under  agreements  of  secrecy,  although  it  must  be  acknowl- 
edged that  this  system  is  somewhat  above  the  average  of 
those  usually  offered.  It  is  not  very  well  adapted  to  the  use 
of  the  physician  in  general  practice,  but  rather  to  those  having 
special  facilities  for  the  care  and  treatment  of  patients. 

It  must  be  borne  in  mind  that  no  system  or  method  of 
treatment  is  so  complete  that  it  will  yield  perfect  results  in  all 
cases,  nor  so  inflexible  that  no  changes  or  variations  may  be 
made  to  meet  the  indications  present.  In  giving  it  here  in 
its  most  essential  parts,  I  am  not  stamping  it  with  my 
approval,  nor  in  fact  the  contrary,  but  more  especially  as  an 
addition  to  our  information  along  these  lines  of  practice. 
The  more  general  knowledge  on  these  subjects  at  our  com- 
mand, the  better  are  we  able  to  successfully  cope  with  the 
various  phases  of  drug,  liquor  and  other  addictions. 


304  SECRET   SYSTEMS  EXPOSED. 

The  following  extract  contains  all  the  essentials  of  the 
method. 

THE  WHISKEY  CURE. 
Injection  Hypoclermatically. 

I£      Strychnine  Nitrate    gr.  85-100 

Atropine  Sulphate gr.  40-100. 

Sol.  Boracic  Acid  2  % fl.  §  j. 

Mix. 

Details.  Take  six  two  drachm  vials,  marked  from  No.  1 
to  No.  6,  and  into  each  of  them  put  100  minims  of  the  above 
formula. 

Leave  vial  No.  1  as  it  is,  without  any  additions.  To 
each  of  the  others  add  nitrate  of  strychnine,  in  the  form  of 
hypodermatic  tablets,  as  follows  : 

To  vial  No.  2  add  five  1-40  gr.  tablets. 

To  vial  No.  3  add  ten  1-40  gr.  tablets. 

To  vial  No.  4  add  twenty  1-40  gr.  tablets. 

To  vial  No.  5  add  thirty  1-40  gr.  tablets. 

To  vial  No.  6  add  forty  1-40  gr.  tablets. 

Commence  the  treatment  with  No.  1  and  continue  for 
three  or  four  days.  If  toxical  effects  are  not  produced  try 
vial  No.  2  for  three  or  four  days,  and  so  on  with  the  other 
numbers  until  you  get  the  effect. 

Or,  you  can  work  this  way :  one  or  two  doses  of  No.  1, 
then  one  or  two  doses  of  No.  3,  then  one  or  two  doses  of 
No.  2,  then  one  or  two  doses  of  No.  1,  skipping  backward 
and  forward  this  way.  Do  not  use  vial  No.  5  and  No.  6 
until  as  a  last  resort  as  the  best  results  are  obtained  by  the 
use  of  vials  No.  1  to  No.  4.  If  the  toxic  effect  is  not  pro- 
duced by  the  time  No.  4  is  reached,  return  again  to  No.  1 
and  proceed  in  same  manner  as  before.  Don't  expect  toxic 
effect  for  four  or  five  days,  viz :  twitching  of  the  muscles, 
stiffness  of  the  jaws,  dryness  of  the  throat,  etc.  As  soon  as 
you  reach  this  point,  go  back  to  No.  1  and  use  that  only. 
You  can  maintain  the  toxic  effect  by  using  the  weakest  solu- 
tion, and  the  least  medicine  given  a  patient  is  always  best. 


SECRET   SYSTEMS  EXPOSED.  305 

THE  DOSE.  The  dose  of  each  of  these  vials  is  five 
minims,  hypodermatically,  and  a  dose  should  be  given  at 
8  A.  M.,  12  M.,  and  4  and  8  P.  M.  Cards  should  be  given 
each  patient  with  the  number  of  vial  and  time  marked 
thereon. 

On  the  fourth  day  of  the  treatment,  ask  your  patient 
if  he  has  a  desire  for  whiskey.  Of  course  some  will  say 
"yes."  Don't  be  alarmed  at  this.  Tell  them  that  you  don't 
see  how  it  is  as  you  are  sure  the  medicine  has  taken  effect  or 
is  about  to  do  so  as  it  usually  does  about  this  time.  Then 
tell  them  you  want  to  see  them  take  a  drink  so  as  to  note 
the  effects,  and  send  them  out  to  purchase  some  whiskey,  as 
you  don't  want  to  furnish  it  to  them,  as  they  might  think  it 
was  drugged.  This  must  be  done  at  one  of  the  regular 
times  for  a  hypodermatic  injection,  and  in  place  of  it  you 
will  substitute  1-10  gr.  Apomorphine,  giving  it  immediately 
before  the  whiskey.  Repeat  this  once  a  day  until  the  taste 
and  smell  of  whiskey  is  disgusting  to  them. 

Never  increase  the  dose  of  any  one  of  the  vials,  on 
account  of  the  Atropine  contained  therein,  but  if  a  stronger 
effect  is  required,  pass  from  one  vial  to  the  other  as  directed. 

Continue  the  regular  treatment  for  three  weeks  or  more 
after  the  taste  and  smell  of  liquor  is  distasteful  or  disgusting 
to  the  patient,  according  to  the  demands  of  each  case.  Cases 
of  Delirium  Tremens  can  be  best  handled  by  using  No.  1 
vial  with  1-250  gr.  of  Hydrobromate  of  Hyoscyamine  added 
to  each  dose. 

WHISKEY  TONIC. 

^     Acid  Muriatic,  Free  C.  P gr.  2048. 

Calcium  Phosphate gr.  768. 

Magnesia  Phosphate gr.   1024. 

Hydrastis    Canadensis gr.  256. 

Quinine  Muriate gr.  256. 

Strychnine   Nitrate gr.   IOJ4- 

Pulsatilla gr.  256. 

Aromatic  Menstrum q.  s.  ad.  Cong.  j. 


306  SECRET   SYSTEMS  EXPOSED. 

Exhaust  the  Hydrastis  and  Pulsatilla  with  sufficient 
dilute  alcohol,  add  the  other  ingredients  secundum  artem, 
and  add  an  aromatic  elixir  to  make  one  gallon.  The  finished 
product  should  contain  20  %  of  alcohol. 

Dose.  One  teaspoonful  every  four  hours,  to  be  taken 
between  the  hypodermatic  injections,  at  6  and  10  A.  M., 
2,  6  and  10  P.  M.,  if  patient  is  awake  first  and  last  hour. 
After  the  hypodermatic  injections  are  discontinued,  continue 
the  use  of  this  tonic  for  a  few  weeks,  twice  a  day,  adding 
1-60  grain  Strychnine  Nitrate  to  each  teaspoonful. 

Before  starting  the  treatment,  obtain  the  full  consent 
and  confidence  of  the  patient,  and  have  him  stop  all  work 
and  worry  for  a  few  days.  This  should  be  observed  in  the 
treatment  of  all  addictions. 

The  maximum  doses  must  be  reached  gradually  and 
when  the  toxic  effects  become  evident  they  should  be  reduced. 
Should  an  antidote  become  necessary  give  plenty  of  whiskey 
and  chloral  hydrate.  It  is  always  necessary  to  exercise  good 
judgment  with  patients,  watching  for  idiosyncrasies  and 
observing  the  action  of  the  heart,  &c.  Begin  treatment  with 
caution,  especially  the  nervous,  weak  and  wornout  patients. 
When  patients  refuse  liquor  the  Atropine  in  the  injection  may 
be  withdrawn,  and  1-60  grain  doses  of  Picrotoxine  substi- 
tuted. If  this  causes  copious  perspiration  it  should  be  with- 
drawn. Warm  baths  should  be  taken  every  two  or  three 
days.  The  bowels  should  be  kept  moving  with  calomel, 
ipecac  and  soda.  Small  quantities  of  liquor  may  be  given 
patients  the  first  day  or  two,  but  then  should  be  discontinued. 

Remarks.  Some  discretion  should  be  used  in  the  selec- 
tion of  whiskey  patients.  Examine  each  case  closely  before 
treatment,  especially  the  action  of  the  heart  and  nervous 
system  that  you  may  note  with  benefit  to  yourself  the  changes 
that  will  be  produced  by  the  action  of  the  remedies  used. 
Question  them  particularly  as  to  why  they  drink,  whether 
for  the  love  of  the  taste  of  it  or  for  the  effect  produced.  If 
the  former  vou  need  not  hesitate  to  take  the  case  and  guaran- 


SECRET   SYSTEMS  EXPOSED.  307 

tee  a  cure,  for  you  will  make  the  taste  and  smell,  even  the 
thought  of  it,  disgusting  to  them.  If  they  drink  for  the 
effect,  don't  fail  to  give  the  treatment  faithfully  and  don't 
omit  the  apomorphine  as  directed,  repeating  each  day  until 
the  taste  is  gone  and  it  becomes  nauseating  to  them.  Whether 
they  drink  for  the  taste  or  effect,  give  the  apomorphine  as 
directed.    . 

THE  OPIUM  AND  MORPHINE  CURE. 

Hypodermatic  Injection.  Same  as  for  whiskey,  viz: 
vials  No.  1  to  No.  6,  given  every  four  hours,  adding  to  each 
injection  1-200  grain  of  Hydrobromate  of  Hyoscyamine. 
Continue  from  one  to  three  weeks  or  longer  as  the  case 
demands. 

Also,  take  Two  Four  ounce  bottles  and  fill  with  the 
Opium  and  Morphine  Tonic,  (see  formula  below)  and  num- 
ber them  No.  1  and  No.  2.  Bottle  marked  No.  1  is  left  as 
it  is,  but  to  bottle  No.  2  add  three-fourths  of  the  amount  of 
morphine  taken  by  the  patient  in  one  day,  either  hypoder- 
matically  or  by  the  mouth. 

Give  the  patient  a  teaspoonful  of  No.  2  four  times  a  day, 
between  the  injections,  and  replace  each  dose  taken  from 
No.  2  with  one  teaspoonful  of  No.  1.  This  is  the  best  sys- 
tem of  gradual  reduction  that  can  be  obtained.  After 
finishing  these  two  bottles,  continue  the  injections  as  before, 
and  the  following 

OPIUM  AND  MORPHINE  TONIC. 

ty     Hydrastis  Canadensis, 
Avena  Sativa, 

Pulsatilla aa  5  viij. 

Cinchona  Rubrum 5  xvj  ■ 

Nux  Vomica, 

Xanthoxylum  Berries aa  %  i j . 

Powd.  Capsicum %  ss. 

Dilute  Alcohol q.  s. 

Aromatic  Menstrum q.  s.  ad.  Cong.  j. 


308  SECRET    SYSTEMS   EXPOSED. 

Exhaust  the  drugs  by  percolating  with  sufficient  dilute 
alcohol  and  add  an  aromatic  elixir,  to  make  one  gallon.  The 
finished  product  should  contain  20  %  alcohol. 

Dose.     One  teaspoonful  every  Four  hours. 

The  morphine  patient  cannot  be  trusted  and  the  attend- 
ing physician  and  nurse  should  always  be  on  the  alert, 
examining  the  pupils  of  the  eye  frequently.  If  you  can  keep 
them  without  using  the  drug  for  a  week  you  may  be  assured 
of  success.  Tell  them  that  you  will  reduce  them  gradually, 
but  do  not  tell  them  when  you  give  them  their  last  dose. 
When  the  change  is  made  from  bottle  No.  2  containing  the 
morphine,  they  will  not  know  the  difference  but  will  think 
they  are  taking  another  bottle  of  the  same.  Any  emergencies 
that  may  arise  should  be  treated  as  in  any  other  case.  Never 
increase  the  hypodermatic  injections;  if  you  want  larger 
doses  pass  from  one  vial  to  the  other  as  directed. 

TOBACCO  CURE. 

For  the  cure  of  the  habit  of  either  chewing  or  smoking- 
tobacco  we  give  the  following  formula : 

I£     Hypodermatic    solution,    same    as 

in  whiskey  treatment 5  ^2. 

Tr.   Plantago  Major 3  y^. 

Tr.  Avena  Sativa 3  34. 

Mix.  Sig.  Give  three  drops  each  time  a  person  feels 
like  taking  a  chew  or  a  smoke,  and  after  each  meal,  asking 
the  patient  to  assist  you  by  lessening  the  number  of  chews 
or  cigars  each  day. 

Give  also  five  minims  from  vials  No.  1  to  No.  4,  hypo- 
dermatically  three  times  a  day.  In  nine  to  fourteen  days 
the  taste  and  smell  of  tobacco  will  become  disgusting.  Stop 
the  use  of  tobacco  entirely  and  continue  the  use  of  the  first 
formula  above  mentioned  by  simply  touching  the  tongue 
with  the  solution  whenever  the  desire  comes  on,  if  it  does  at 
all,  or  three  to  six  times  a  day  for  a  while,  even  if  no  desire 
is  noticed. 


SECRET    SYSTEMS   EXPOSED.  309 

The  Whiskey  Tonic  may  also  be  given  for  a  week  or 
ten  days,  a  teaspoonful  three  times  a  day.  If  after  the  ninth 
day  the  patient  still  persists  in  chewing  or  smoking,  give 
1-10  grain  apomorphine  after  a  chew  or  a  cigar,  and  con- 
tinue this  once  a  day,  at  the  time  for  the  regular  injections. 

CIGARETTE  CURE. 

Begin  the  treatment  by  giving  hypodermatic  injections 
from  vials  No.  1  to  No.  4  every  four  hours,  adding  to  each 
dose  1-40  grain  of  Picrotoxine.  Continue  this  until  patient 
sweats  copiously.  Then  have  an  attendant  give  the  patient 
a  hot  sponge  bath,  or  steam,  cooling  him  off  gradually,  with 
a  shower,  rubbing  until  dry. 

Use  now  the  following  formula  hypodermatically,  two 
to'  four  times  a  day. 

3$     Whiskey   Injection fl.   3  ij. 

Tr.  Cannabis  Indica TU  v. 

Mix.  Sig.  Five  to  ten  minims  hypodermatically,  as 
above  directed,  using  your  judgment  in  individualizing  your 
case,  the  dose  to  be  used  and  the  number  of  them  per  day. 
Continue  these  injections  at  least  three  to  four  weeks.  Give 
also  at  the  same  time  the  following  formula : 

I£     Whiskey  Tonic fl.  5  v. 

Tr.  Avena  Sativa fl.  §  j. 

Mix.  Sig.  One  teaspoonful  three  to  four  times  a  day. 
If  patient  becomes  very  nervous  use  the  following  formula : 

J£     Thein,    (Merck) gr.  viij. 

Acid  Boracic gr.  ij. 

Aqua  Destil fl.   5  j. 

Mix.  Sig.  Inject  from  Five  to  Ten  drops  as  often  as 
required,  as  your  discretion  indicates. 

The  hypodermatic  injections  are  usually  given  at  8  A. 
M.,  12  M.,  and  4  and  8  P.  M.  The  tonic  at  6  A.  M.  and 
between  the  injections.  The  number  of  cigarettes  should  be 
decreased  by  1-2  or  1-3  each  day,  and  in  four  or  five  days 
discontinue  them  entirely.     If  the  patient  stubbornly  persists 


310  SECRET    SYSTEMS   EXPOSED. 

in  smoking  give  him  the  usual  dose  of  Apomorphine 
immediately  after  lighting  a  cigarette,  and  continue  this 
daily  until  he  becomes  disgusted  with  them.  The  entire 
treatment  should  consume  from  four  to  six  weeks. 

REMARKS — The  alkaloids  mentioned  in  this  system 
can  be  purchased  from  first  class  drug  houses,  in  hypoder- 
matic tablets.  No  crude  or  commercial  drugs,  or  tablets, 
or  triturations  should  ever  be  used  hypodermatically.  Sharp 
&  Dohme,  of  New  York  and  Baltimore,  are  at  present  the 
only  house  listing  the  Hydrobromate  of  Hyoscyamine. 


The  Keeley  System. 

The  following  formulae  were  given  me  by  a  physician 
who  was  formerly  employed  in  a  Keeley  Institute,  with  the 
assurance  that  they  are  correct.  The  same  formulae  are 
published  in  a  small  booklet  published  by  a  physician  in  the 
West,  which  corroborates  the  statement  made  by  the  physi- 
cian giving  them  to  me.  I  give  them  here  for  what  they 
may  be  worth,  assuming  no  responsibility  for  whatever 
results  may  follow  their  use. 

On  entering  the  institute  the  patient  is  given  a  mixture 
containing  the  following : 

I?     Gold  and  Sodium  Chloride gr.  xxx. 

Strychnine  Nitrate gr.  iv. 

Atropine    Sulphate gr.  j. 

Glycerine    fl .   %  ij. 

Fl.  Ext.  Cinchona  Comp .  .q.  s.  ad.  fl.  5  xvj- 

Mix.    Sig.    One  teaspoonful  in  water  three  times  a  day. 
In  addition  to  the  above,  the  patient  receives  a  hypoder- 
matic   injection    of    strychnine    nitrate,    in    doses    that   will 
produce  its  physiological  effect.     1-60  grain  additional  will 
usually  be  all  that  is  required,  but  it  can  be  used  as  necessary. 


SECRET    SYSTEMS   EXPOSED.  311 


R  Solution. 


I£     Acid  Boracic gr-  iv- 

Aqua  Dest A.   o  ij- 

Mix  and  bring  to  boiling  point  and  add 

Strychnine  Nitrate gr.  ss. 

Cool  and  filter  and  bring  up  to  2  ounces  by  adding 
Aqua  Dest.  Color  red  with  Tr.  Cudbear.  Dose  Five  to 
Ten  minims  hypodermatically.  This  is  begun  when  patient 
is  sober  and  continued  during  the  treatment.  Give  an  injec- 
tion every  four  hours. 

T  Solution. 

^     Acid  Boracic gr-  xx- 

Aqua  Destil  A.   5  j. 

Them  Muriate gr.  viij. 

Mix.  Filter.  Bring  the  water  and  boracic  acid  to 
boiling  point  before  adding  the  Thein  Muriate. 

Dose.  Five  to  Ten  Minims  every  four  hours,  by  hypo- 
dermatic injection.     This  is  the  "sobering  up"  solution. 

P.  Solution. 

3$     Pilocarpine  Muriate gr-  viij. 

Acid  Boracic   gr-  xx- 

Aqua  Destil A.  o  j- 

Mix  in  same  manner  as  previous  solution. 
Dose  Five  to  Six  minims.    This  is  used  in  the  tobacco 
treatment,  or  to  produce  sweating  at  any  time  should  the 
skin  become  too  dry.    It  causes  some  nausea. 

M  Solution. 

Magendie's  solution  of  Morphia. 
For  nervousness  during  liquor  treatment,  as  necessary. 

If  the  desire  for  liquor  does  not  disappear  in  a  few  days, 
atropine  sulphate  is  given  hypodermatically  in  sufficient 
doses  to  produce  its  full  physiological  effect. 


312  SECRET    SYSTEMS   EXPOSED. 

The  strychnine  solution  is  colored  red,  as  shown  in 
formula ;  the  atropine  solution  is  left  colorless,  solution 
being  made  with  distilled  water ;  the  apomorphine  solution  is 
kept  in  a  blue  bottle.  When  the  patient's  appetite  for  liquor 
does  not  disappear,  in  connection  with  the  strychnine  and 
atropine  solutions,  he  receives  in  addition  an  injection  from 
the  blue  bottle. 

In  the  language  of  the  inmates  of  the  institution,  this 
arrangement  of  the  colors,  red,  white  and  blue,  has  been 
termed  the  "barber  pole"  and  whenever  the  apomorphine 
solution  was  used,  the  patient  was  said  to  have  received  the 
barber  pole. 

The  formula  of  the  apomorphine  solution  is  as  follows : 

Add  1-20  grain  Apomorphine  to  Eight  minims  of  "T" 
solution  and  Four  minims  of  "R"  solution. 

Inject  this  hypodermatically  and  follow  with  a  drink  of 
whiskey. 

This  will  sicken  them  and  will  render  the  taste  and 
smell  nauseating  to  them.  Give  this  at  a  regular  injection 
hour. 

When  the  desire  foriiquor  has  been  gone  for  several 
days,  the  following  internal  treatment  is  gradually  substi- 
tuted for  the  first  formula.  They  may  be  alternated  for  a 
few  days,  before  discontinuing  the  first  formula  entirely. 

INTERNAL  TREATMENT. 

I£     Ext.  Cinchona,  solid gr.  xl. 

Grd.  Gentian  Root §    ij. 

Powd.  Capsicum gr.  xx. 

Mix  and  boil  in  Four  pints  of  water  for  Twenty  min- 
utes, and  add 

Glycerine fl.   %  iij. 

Remove  from  the  fire  and  add  Grd.  Bitter  Orange  Peel, 
5  ss.    Let  stand  until  cool,  and  strain.    Color  with  Caramel. 
Sig.     One  teaspoonful  every  2  hours  in   1-2  glass  of 
water. 


SECRET   SYSTEMS   EXPOSED.  313 

After  cure,  continue  same  four  times  a  day  for  a  few 
weeks. 

If  patient  wants  whiskey,  (first  request)  precede  by  a 
full  dose  of  Calomel.  If  he  persists  give  1-20  grain  Apo- 
morphine  with  each  drink. 


FOR  ALCOHOLIC  GASTRITIS. 

J£     Pepsin  Sacch gr.  el. 

Bismuth  Sub  Nitrate gr.  c. 

Powd.  Capsicum gr.  xx. 

Mix.  Ft.  Pulv.  No.  xx. 
Sig.     One  every  four  hours. 


FOR  NEURASTHENIA. 

^     Tr.  Cinchona  Rub fl.  §  ij. 

Fl.  Ext.  Kola fl.  I  ij. 

Fl.  Ext.   Scutellaria ' fl.  §  j. 

Elixir  Aromatic q.    s.   ad.  fl.  %  vj. 

Mix.  Sig.  One  teaspoonful  in  1-2  glass  of  water  four 
times  a  day. 

Also  "T"  solution.  Five  to  Seven  minims  four  times  a 
day. 

KEELEY  TOBACCO  TREATMENT. 

Inject  Three  to  Five  minims  of  "P"  solution  every  other 
day,  and  Five  to  Seven  minims  of  "T"  solution  four  times 
a  day.     Also  the  following  formula: 

I£     Fl.  Ext.  Calumba fl.  5  ss. 

Tr.  Quassia fl.  %  ss. 

Sp.  Vini  Rect fl.  §  ss. 

Aqua q.     s.   ad.  fl.  §  iv. 

Mix.     Sig.     One  teaspoonful  every  two  hours. 


3  14  SECRET    SYSTEMS    EXPOSED. 


Tri-Elixiria. 

As  a  treatment  for  drug  addiction,  more  especially 
opium  and  morphine,  the  Tri-Elixiria  remedies  have  been 
rather  extensively  advertised  in  medical  periodicals,  and  on 
this  account  inquiries  as  to  their  composition  are  occasionally 
received. 

Personally,  knowledge  of  this  treatment  is  limited  to  but 
one  patient  who  applied  to  me  for  treatment,  after  spending 
some  time  at  the  sanatorium  in  Memphis,  Tenn.,  where  the 
treatment  was  employed  under  the  direction  of  those  inter- 
ested in  its  manufacture  and  sale. 

This  patient,  a  physician,  coming  to  me  for  treatment 
for  a  mild  form  of  morphine  addiction,  is  sufficient  evidence 
of  the  failure  of  the  treatment  through  which  he  had  just 
passed. 

In  regard  to  Mandragora,  the  drug  upon  which  they 
seem  to  place  chief  reliance,  the  following  comment  is  made, 
quoted  from  the  U.  S.  Dispensatory :  "Mandragora  is  a  per- 
ennial European  plant  with  a  spindle-shaped  root,  which  is 
forked  beneath,  and  is  therefore  compared  with  the  human 
figure.  In  ancient  times,  this  root  was  supposed  to  possess 
magical  virtues,  and  was  used  as  an  amulet  to  promote 
fecundity.  It  was  much  used  by  the  ancients  with  a  view 
to  its  narcotic  effects.  It  is  unknown  as  a  remedy  in  the  U. 
S."  This  last  statement  is  open  to  question,  as  in  Prof. 
Waugh's  excellent  work,  "The  Treatment  of  The  Sick,"  the 
following  statement  is  made:  "Mandragorine  (Alk.,)  sup- 
posed to  be  the  active  principle  in  the  Keeley  cure  for  alco- 
holism. Dose :  Gramme,  0.00025 ;  grain,  1-250,  cautiously 
increased,  hypodermically."  Mandragorine  is  also  mentioned 
in  an  article  written  by  Prof.  Waugh  in  1894,  on  the  treat- 
ment   of   alcoholism.      He    says    "Decidedly,    mandragorine 


SECRET    SYSTEMS   EXPOSED. 


M5 


excels  atropine — the  former  being  less  unpleasant  and  more 
efficient." 

Mandragorine  is  the  alkaloid  of  Mandragora  Officinalis, 
first  isolated  by  Crouzel.  It  resembles  atropine  in  its  action 
but  it  is  not  indentical  with  it.     It  dilates  the  pupil. 

The  literature  of  the  company  contains  the  statement 
that  in  order  that  physicians  may  prescribe  Tri-Elixiria 
intelligently,  the  component  parts  of  the  remedy  are  made 
known,  and  are  as  follows :  The  absence  of  the  definite 
quantity  of  "Mandragora  Off.'*'  in  the  formula,  is,  in  the 
light  of  the  appended  extract  from  the  Alkaloidal  Clinic, 
quite  significant. 

The  formula : 


B 


Rhubarb,   (F.  E.,) .  . 

TTl    iv. 

Prickley  Ash,  (F.  E.,).... 

TTl   iv. 

Colombo,   (F.  E.,) 

TTL    V. 

Hops,  (Elixir,) 

TTL  ix. 

Lactucarium,    (Elixir 

,) 

TTl   vj. 

Celery,  (Elixir,)  .... 

TTl   viij. 

Brew   

TTl   viij. 

Gentian,   (F.  E.,) .  . . 

TTl   v. 

Scull  Cap.',  (F.  E.,) . 

Til  iij- 

Valerian,  (F.  E.,)  .  .  . 

TTl   V. 

Licorice,  (F.  E.,)  .  .  . 

TU   "J- 

Ammonia,  (Mur.,)  .  . 

gr-  ij- 

Hydrastia,    (Mur.,)  . 

gr.   1-16 

Mandragora  Off.  (E: 

ct.,)  .  .  . 

.  .  .q.  s. 

Dose.  One  teaspoonful  in  1-4  glass  of  water  eight  times 
a  day,  for  opium  and  its  preparations,  as  Morphine.  Lauda- 
num, etc.,  and  for  other  drug  addictions. 


316  SECRET    SYSTEMS   EXPOSED. 

The  Mandragorine  Fake. 

The  following-  is  clipped  from  the  Alkaloidal  Clinic : 

We  have  received  a  number  of  requests  for  information 
as  to  Mandragorine ;  and  as  we  are  originally  responsible  for 
the  attention  paid  to  this  alkaloid,  we  herewith  give  some 
pointers  as  to  it. 

Benjamin  Ward  Richardson  made  some  experiments 
with  mandragorine  and  stated  that  there  were  certain  differ- 
ences between  its  action  and  that  of  atropine.  A  very  acute 
observer  who  had  studied  this  matter  while  taking  the  Keeley 
treatment  for  alcoholism  came  to  the  conclusion  that  man- 
dragorine was  the  agent  used  hypodermically,  as  the  effects 
corresponded  with  those  described  by  Richardson.  Inquiry 
failed  to  find  any  mandragorine  in  the  country ;  in  fact  the 
only  supply  we  could  obtain  was  a  small  lot  of  the  man- 
dragora  root  discovered  in  a  country  drug  store,  from  which 
we  had  the  alkaloid  extracted  and  made  up  into  tablets.  This 
we  believe  is  the  only  mandragorine  that  has  been  in 
America  during  the  past  ten  years. 

We  corresponded  with  Merck  in  relation  to  a  supply,  but 
found  that  it  could  only  be  obtained  by  special  arrangement, 
since  there  was  no  call  for  it  and  none  was  prepared  for  the 
trade.  This  would  run  the  cost  into  hundreds  of  dollars, 
more  than  the  importance  of  the  article  justified,  especially 
as  mandragorine  is  simply  a  mixture  of  atropine  and  hyos- 
cine,  and  not  in  fixed  or  invariable  proportions.  As  it  is  an 
easy  matter  to  mix  these  agents  to  suit  ourselves  in  prescrib- 
ing, it  did  not  seem  advisable  to  import  the  "mandragorine." 
In  the  mean  time  the  matter  has  been  taken  up  by  a  number 
of  the  dealers  in  secret  methods  of  treating  alcohol  and  drug 
habits,  probably  because  the  general  and  medical  public 
knows  nothing  about  mandragorine  and  cannot  procure  it. 
This  offers  the  desirable  situation  of  non-secrecy  and  impos- 
sibility of  obtaining  a  supply  except  through  the  exploiters; 
and  under  this  very  ethical  arrangement  the  usual  morphine 
may  be  dispensed  as  a  cure  for  the  morphine  habit,  cocaine 


SECRET    SYSTEMS   EXPOSED.  317 

to  cure  the  cocaine  habit,  alcohol  to  cure  the  whiskey 
habit,  etc. 

If  any  one  desires  to  use  "mandragorine"  he  may  give 
hyoscine  gr.  1-100  with  atropine  gr.  1-250,  and  he  will  have 
it,  without  the  expense.  The  advertisements  tendering  this 
alkaloid  are  to  be  placed  on  a  par  with  those  offering  "red 
lava  flower,"  "halish  sativa,"  etc. 

In  order  to  learn  whether  any  one  was  really  buying 
mandragorine,  we  wrote  to  the  leading  purveyors  of  alka- 
loids, asking  if  they  could  supply  it.  We  append  the  only 
reply  received.     The  deduction  is  obvious. 

"New  York,  July  16th,  1903. 

"We  are  in  receipt  of  your  favor  of  the  nth  inst.,  and  in 
reply  would  say  that  we  are  not  in  a  position  to  furnish 
mandragorine.  In  this  connection  we  would  mention  that 
some  years  ago  a  certain  investigator  believed  he  had  dis- 
covered in  atropa  mandragora  a  new  alkaloid  which  he 
named  "mandragorine."  Subsequent  investigations,  how- 
ever, have  proved  this  supposedly  new  alkaloid  to  be  a  mix- 
ture in  which  hyoscyamine  predominates — practically  impure 
hyoscyamine.  Trusting  that  the  above  information  will  be 
of  interest  to  you,  we  are, 
"Faithfully   yours, 

"Merck  &  Co." 


The  "Husa"  Swindle. 

A  few  years  ago,  the  medical  profession  was  considera- 
bly interested  in  an  article  that  was  being  widely  quoted  by 
medical  journals,  regarding  the  discovery  by  a  physician 
from  Texas,  of  a  plant  which  had  the  power  to  neutralize  the 
poisons  communicated  to  persons  bitten  by  all  kinds  of 
venomous  serpents  and  reptiles,  and  which  also  enabled  any 
physician    to   cure   the   opium   or   morphine   habit   in    short 


318  SECRET    SYSTEMS   EXPOSED. 

order.  This  drug  he  called  "Husa,"  and  its  origin  was  said 
to  be  in  the  everglades  of  Florida.  Samples  of  the  crude 
drug  could  not  be  obtained,  but  the  doctor  kindly  consented 
to  supply  a  liquid  preparation  of  it  at  a  fancy  price.  The 
interest  manifested  in  it,  culminated  in  a  scientific  investi- 
gation, and  analysis  being  made  by  Prof.  John  Uri  Lloyd, 
of  Cincinnati,  whose  report  was  read  at  a  joint  meeting  of 
the  Cincinnati  Chemical  Society,  and  the  Cincinnati  Academy 
of  Pharmacy,  from  which  his  deduction  is  quoted :  "To  sum 
up,  'Husa'  is  a  liquid  containing  large  amounts  of  morphine 
sulphate,  some  salicylic  acid,  some  alcohol,  water,  glycerine 
and  coloring  matter,  probably  burnt  sugar.  I  would  define 
'Husa'  as  follows — A  solution  of  morphine  to  be  adminis- 
tered under  the  name  of  'Husa,'  and  only  by  physicians.  It 
is  sold  to  physicians  at  the  rate  of  ten  dollars  for  about  two 
hundred  and  thirty-four  grains  of  morphine.  Until  I  am 
furnished  with  a  new  plant,  containing  morphine  to  the 
extent  found  in  these  experiments,  I  shall  accept  that  'Husa' 
is  a  concoction."  The  medical  profession  has  been  imposed 
upon  so  much,  that,  it  is  well  to  investigate  closely  all  "new 
and  startling  discoveries"  before  investing  anything  in  them. 


The  Ideal  Hernia  Cure. 

This  treatment  is  at  present  being  advertised  in  several 
medical  journals,  the  formula  being  a  secret  one.  Physicians 
desiring  knowledge  of  the  secret  are  obliged  to  send  ten 
dollars  to  the  Ideal  Chemical  Co.  of  St.  Paul,  and  in  return 
receive  a  small  folder  containing  the  formula  and  directions 
for  its  use.  together  with  a  hypodermatic  syringe. 

The  following  extract  from  their  pamphlet,  kindly 
loaned  to  me  by  one  who  purchased  it  from  the  above  firm, 
gives  all  the  leading  points  of  the  treatment.  It  will  be 
noticed  by  all  who  are  even  only  fairly  informed  on  this 
subject,   that  nothing  new   is   offered.      True,   the   formula 


SECRET   SYSTEMS  EXPOSED.  319 

may  differ  from  others,  yet  there  are  hundreds  of  compounds 
that  will  cure  hernia  if  properly  injected. 

I  have  investigated  many  of  the  secret  methods  adver- 
tised to  physicians  and  it  is  indeed  seldom  that  anything  is 
offered  that  is  new  or  original,  or  of  any  more  advantage 
to  the  physician  than  formulae  and  methods  which  are 
published  in  practical  medical  journals  and  books  on  the 
subjects. 

Details  of  Treatment.  The  day  previous  to  the  operation, 
administer  a  large  dose  of  sulphate  of  magnesia,  to  thor- 
oughly clean  the  intestinal  tube.  Everything  being  favorable, 
place  the  patient  in  bed,  having  the  head  and  shoulders  low, 
and  the  pelvis  slightly  raised.  Explore  the  inguinal  canal 
and  rings  thoroughly  and  see  that  the  hernia  is  completely 
reduced.  Now  invaginate  the  scrotum  with  the  forefinger 
of  the  left  hand  and  locate  the  external  ring,  then  with  the 
thumb  of  the  same  hand  press  from  above  downward  on  the 
integument  directly  over  the  external  ring.  The  integument 
and  tissues  being  firmly  held  between  the  forefinger  and 
thumb,  the  needle  is  pressed  down  beside  the  thumb  until 
the  point  reaches  just  below  and  under  the  arch  of  the 
external  ring.  The  instrument  is  now  lowered  and  the  point 
slipped  under  the  arch  of  the  external  ring  and  passed  up 
the  canal  in  the  sub  serous  areolar  tissue  until  it  reaches  the 
internal  ring.  The  fluid  is  then  slowly  distributed  over  the 
interior  of  the  canal  and  around  the  margins  of  the  ring 
as  the  instrument  is  withdrawn. 

A  compress  is  now  applied  over  the  side  of  the  hernia 
and  a  figure  8  bandage  applied  around  the  body  and  thigh 
of  the  affected  side,  enjoining  positive  rest  for  two  days. 
From  five  to  fifteen  drops  of  the  solution  should  be  injected 
at  each  treatment,  and  should  be  repeated  once  a  week  until 
assured  of  the  proper  formation  of  plastic  material  to  warrant 
a  permanent  cure.  The  truss  commonly  used  may  be  worn 
during  the  interim.  It  is  seldom  necessary  to  give  more 
than  six  treatments  to  secure  satisfactory  results,  and  in 
cases  of  children  one  or  two  treatments  may  be  sufficient. 


320  SECRET   SYSTEMS  EXPOSED. 

The  formula  is : 

Glycerole  of  Tannic  Acid grs.  xc. 

Glycerine  fl.  5  j. 

Mix. 

Of  this  solution  take  two  drachms,  and  add  Alcohol, 
one  drachm,  and  Tr.  Cantharides,  one  drachm.  Mix  all  and 
shake  thoroughly. 

Note.  There  is  no  official  preparation  known  as 
Glycerole  of  Tannic  Acid,  but  the  composition  of  Glycerite 
of  Tannic  Acid  is  approximately  90  grs.  to  the  ounce  of 
glycerine.  The  formula  is  obscure  as  written  and  appears 
to  be  another  example  of  non  secrecy  combined  with 
impossibility. — J.  D.  A. 


Excelsior  Hernia  Fluid. 

The  following  is  the  formula  of  the  Excelsior  fluid  for 
the  treatment  of  hernia.  It  was  formerly  sold  as  a  secret 
formula,  but  like  many  others,  was  disclosed  and  given  to 
the  profession. 

I  have  not  used  this  compound  but  would  not  hesitate 
to  do  so.     From  its  composition  it  evidently  possesses  merit. 

1^     Sulphate  of  Zinc gr.  x. 

Carbolic  Acid TT\,  vj. 

Guaiacol   n\,  xv. 

Lloyd's  Spec.  Tr.  Thuja 3  j. 

Fid.  Ext.  White  Oak 3  ij. 

Oil  of  Cinnamon TTL  ij. 

Glycerine    3  ij. 

Water q.  s.  ad.  5  j. 

Mix. 

Dissolve  the  sulphate  of  zinc  in  the  water,  add  the 
glycerine,  carbolic  acid,  oil  of  cinnamon  and  guaiacol.  Mix 
thoroughly  and  add  the  remaining  ingredients.  Let  stand 
for  a  week,  with  frequent  agitation,  after  which  filter  through 
paper. 


SECRET   SYSTEMS   EXPOSED.  32  I 

Dr.   Coffevs  System  of   Treating 

Rectal  Diseases. 

The  following  set  of  formulae  was  kindly  furnished  me 
by  a  physician  located  in  the  middle  West,  who  informs  me 
that  this  secret  system  was  sold  throughout  his  section  at 
prices  varying  from  $350  to  $1200,  under  an  agreement  of 
secrecy. 

As   quite  a   number  of  physicians   have  made   inquiry 
regarding  this  treatment.  I  am  pleased  to  be  able  to  furnish 
the  information  desired. 
Hemorrhoidal  Fluid. 

R      Campho-Phenique    3  vj. 

Naphthalin    5  j. 

Morphia  Sulph gr.  x. 

Pulv.  Hydrastis   gr.  xl. 

Acid  Carbolic 3  iv. 

Mix.    Let  stand  ten  days,  then  filter. 
Sig.     Inject   four  to  six  minims,  according  to  size  of 
hemorrhoid. 


For  Healing  Ulcers  and  Fistulae. 

R      Gum  Camphor gr.  xx. 

Morphia  Sulph gr.  xx. 

Xaphthalin    gr.  xx. 

Pulv.  Hydrastis   gr.  xl. 

Acid  Carbolic 3  iv. 

Vaseline *  ij . 

Mix.     Make  an  ointment. 

Note.  C  Carbolic  acid  cannot  be  incorporated  with  vas- 
eline in  this  proportion  so  as  to  remain  in  permanent  sub- 
division, but  separation,  due  to  crystalization,  will  take  place. 
Adeps  lanum.  fresh  lard  or  suet  should  be  substituted  for 
the  vaseline. — J.  D.  A.) 


3^2  SECRET   SYSTEMS  EXPOSED. 

For  Healing  After  Piles  Have  Sloughed  Off. 
I*     Linseed  oil, 

Sweet  oil, 

Rosin, 

Mutton   Tallow . aa  §  iv. 

Yellow    Wax %  iij . 

Mix  by  melting  all  together  and  strain  through  a  thin 
cloth,  and  stir  until  cool. 

For  "Ease"  when  piles  are  painful,  Cocaine,  two  grains 
to  the  ounce  of  vaseline,  is  recommended. 

For  Hemorrhage,  the  use  of  Monsell's  Solution  is 
advised. 

After  injection  of  piles  the  tumors  are  painted  with  a 
solution  composed  of  eight  grains  of  morphine,  and  one 
ounce  each  of  Tr.  Opii  and  Olive  oil. 


THE  SLANDAIS  PILE  TREATMENT. 

Sold  to  the  profession  some  years  ago  under  an  agree- 
ment of  secrecy.    First, 

I£     English  Rosin i   lb. 

Creolin, 

Oil  Gaultheria aa  fi .  3  iv. 

Melt  together  and  when  cooling  divide  into  blocks  half 
the  size  of  a  hen's  egg. 

Second.  Add  a  tablespoonful  of  Sodium  Biborate  and 
a  teaspoonful  of  Carbolic  Acid  to  three  pints  of  water.  Use 
hot  and  bathe  the  pile  tumors  for  ten  minutes. 

Third.  After  bathing  the  piles  place  a  shovel  full  of 
wood  ashes  into  a  chamber,  also  one  block  of  the  first  named 
remedy,  and  place  a  live  coal  against  it.  While  it  burns 
have  the  patient  sit  on  the  chamber  and  allow  the  smoke  to 
come  in  direct  contact  with  the  piles.  The  medicinal  prop- 
erties are  conveyed  in  the  smoke.  Repeat  four  or  five  times 
in  twenty- four  hours,  until  cured.  After  bathing,  dry  the 
piles  before  taking  the  smoke  treatment. 


SECRET    SYSTEMS   EXPOSED.  323 

The  Brinkerhoff  System. 
For  Piles  and  Other  Rectal  Diseases. 


Hemorrhoidal  Fluid. 

This  secret  formula  is  frequently  seen  reported  to  be 
one  ounce  of  carbolic  acid,  eight  grains  of  chloride  of  zinc 
and  five  ounces  of  olive  oil.  Any  one  who  has  seen  the 
compound  as  prepared  by  its  manufacturers,  who  still  supply 
it,  knows  that  this  is  not  the  correct  formula.  By  tests  the 
percentage  of  carbolic  acid  is  evidently  much  larger,  and 
the  oil  used  is  undoubtedly  sperm  oil. 

I  obtained  some  of  this  fluid  indirectly,  several  years 
ago,  and  I  noticed  that  it  was  slightly  colored  with  per- 
manganate of  potassium.  On  standing  for  some  time  this 
color  fades,  due  to  the  oxidization  which  takes  place. 
Judging  from  its  action  when  injected,  and  its  action  on 
mucous  membrane  generally,  it  is  probably  a  fifty  to  sixty- 
five  per  cent  solution  of  carbolic  acid  in  sperm  oil.  The  elder 
Brinkerhoff  had  a  formula  patented  which  he  claimed  was 
that  of  his  pile  injection,  but  this  is  a  most  glaring  deception. 
The  following  was  taken  from  the  records  of  the  patent 
office  in  Washington : 

"Take  a  quantity  of  sperm  oil,  place  it  in  a  dish  at  a 
temperature  of  twenty-four  degrees  F.,  and  add  strong 
carbolic  acid  to  the  oil  until  white  feathery  crystals  begin 
to  form,  stirring  all  the  while." 

The  impossibilities  in  these  directions  appear  in  every 
line. 

Sperm  oil  at  twenty-four  degrees  F.  is  a  solid  body, 
almost  as  hard  as  a  stone,  as  is  also  pure  carbolic  acid. 

If  an  acid  were  used  in  which  a  sufficient  quantity  of 
water  or  glycerine  was  present  to  keep  it  liquid,  it  would 
not  mix  with  sperm  oil  at  any  temperature.  The  intent  to 
deceive  is  therefore  apparent. 


324  SECRET    SYSTEMS   EXPOSED. 

The  following  is  his  treatment  for  Fistula : 

1^     Dist.  Ext.  Hamamelis fl.   5  v. 

Liq.  Ferri  Subsulph fl.  3  j. 

Acid  Carbolic,   Cryst gr.  ij . 

Glycerine    fl.  5  ij . 

Mix.  For  Fistula  in  ano  inject  ten  to  fifteen  drops  deep 
into  the  fistula,  and  press  the  track  of  the  fistula  with  the 
finger  to  force  the  fluid  in  more  deeply. 

In  cases  of  Rectal  Ulcer  he  gives  the  following  treat- 
ment :  To  an  ounce  and  a  half  of  water  add  half  a  teaspoon- 
ful  of  starch  and  half  a  teaspoonful  of  the  formula  above 
given,  and  inject  into  the  rectum  every  night.  Sometimes 
he  orders  an  injection  of  starch  into  the  rectum  in  the  morn- 
ing after  the  bowels  have  moved. 

His  system,  as  applied  to  Fissure  of  the  Anus,  is  this : 
Once  or  twice  a  month  the  ulcer  is  cleaned  and  a  solution  of 
nitrate  of  silver,  40  grains  to  the  ounce,  is  applied  to  it. 
Between  these  treatments  the  patient  uses  a  morning  and 
evening  treatment  himself.  Each  morning  he  is  to  evacuate 
the  bowels,  then  inject  into  the  rectum  luke  warm  water,  and 
afterwards  insert  a  little  ointment  consisting  of  three  grains 
of  carbolic  acid  and  eight  grains  of  sulphur  to  the  ounce  of 
vaseline  or  lard.  For  evening  treatment  he  uses  the  ulcer 
treatment,  in  the  manner  above  given  under  Rectal  Ulcer. 

Alternating  with  the  above  treatment  for  Fissure,  he 
applies  the  following  ''Fissure  Compound"  : 

B     Ac.   Carbolic    3  iv. 

Oil  Sweet  Almonds    3  ij. 

Mix. 

Sig.  Apply  with  cotton  tipped  probe,  lightly  along  the 
track  of  the  fissure. 


SECRET   SYSTEMS   EXPOSED.  325 


Dr.  Armstrong's  "Vril." 

Also  Known  as  Po-pi-na,  Mastico,  Golden  Manna,  and  The 
Great  Cell  Irritant. 
The  formula  of  this  preparation  is  as  follows,  obtained 
from  the  originator.  It  has  been  advertised  for  several  years 
in  a  number  of  medical  journals,  and  is  furnished  on  receipt 
of  two  dollars.  In  his  advertisements,  Dr.  Armstrong  makes 
some  astonishing  statements,  and  repeats  them  without 
reserve  in  his  letters  to  inquirers. 

^      Coarse  Wheat  Bran,  browned O  j. 

Soluble  Citrate  of  Iron o  iij. 

Sugar,  granulated 0  ij_nj- 

Mix.  Sig.  One  heaping  teaspoonful  morning,  noon 
and  night.     Best  taken  in  milk  or  cream,  q.  s. 

If  patient  is  under  forty-five  years  old  and  not  very 
feeble,  give  one  and  one-half  teaspoonful  doses. 

The  bran  is  to  be  browned  in  an  oven  same  as  coffee. 
It  must  be  moderately  coarse.  The  coarse  particles  are  best 
obtained  by  sieving  the  fine  particles  out  and  using  what 

remains. 

When  extra  cell  irritation  is  desired,  instead  of  the 
citrate  of  iron,  citrate  of  iron  and  ammonia  may  be  used  in 
same  quantity.  The  preparation  is  also  made  in  the  form 
of  small  blocks,  of  which  the  following  is  the  formula  : 

B     Gum   Tragacanth    5  j  ■ 

Citrate  of  iron  and  Ammon, 

Tannin    '■  • -aa  5  iij. 

Light  Brown  Sugar o  xij- 

Oil   of    Orange '. A.  *  ss. 

Coarse  Wheat  Bran,  browned O  v. 

Alcohol    O  j 

Water    q.   s. 

Place  the  Gum  tragacanth  in  sufficient  water  to  dissolve 


326  SECRET   SYSTEMS-  EXPOSED. 

it  so  as  to  make  the  solution  of  the  consistency  of  cream. 
Add  the  iron  and  tannin  to  this  and  mix.  Knead  the  bran 
into  this  and  make  a  mass,  adding  the  alcohol  in  which  the 
oil  of  orange  has  been  dissolved,  with  the  sugar  and  sufficient 
water  to  make  a  mass  the  consistence  of  dough.  Roll  out 
the  mass  to  the  thickness  of  1-4  to  1-3  inch  and  cut  into 
blocks  one  inch  square.  Dust  with  powdered  sugar  and 
box.  Dose,  one  to  two.  The  bran  must  not  be  used  fine, 
nor  made  fine  during  manipulation. 

Quoting  from  a  letter  written  to  me,  the  doctor  says : 
''I  enclose  the  formula  which  I  used  for  many  years. 
I  put  it  up  in  paper  boxes,  mahogany  colored,  with  gilt 
letters,  as  a  great  cure  for  consumption  and  all  chronic 
diseases.  I  always  give  other  remedies  with  it  but  only  for 
appearance,  as  this  formula  does  all  the  work.  It  irritates 
the  great  lining  of  the  alimentary  canal.  I  have  cured  many 
bed-fast,  hopeless  cases  of  consumption,  too  feeble  to  rise 
up  in  bed,  wasted  to  the  greatest  extreme,  hectic,  etc.  In 
many  cases  they  would  get  out  of  bed  in  three  to  five  days 
and  walk  about  the  house  and  were  cured  in  two  or  three 
months.  It  loosens  cough  and  rapidly  builds  up.  The 
feebler  the  patient,  the  more  marked  and  rapid  the  gain.  It 
does  not  cure  all  cases  of  consumption,  but  vastly  more 
than  all  things  known  to  science,  so  also  with  women  and 
children  and  all 'conditions  of  debility.  I  have  known  it  to 
cure  a  woman  of  cancer  of  the  breast  in  twenty  days.  It 
was  an  open,  discharging,  painful  cancer.  A  young  woman 
with  consumption  had  not  raised  her  head  from  the  pillow 
for  months,  and  had  taken  but  three  tablespoonfuls  of  food 
in  four  days  previous  to  taking  this  cell  irritant,  and  in 
seven  days  after  beginning  it,  she  went  out  riding  and  ate 
three  fair  meals  a  day.  In  convalescence,  after  fevers  or 
child-birth,  where  the  patient  is  low,  with  dry  and  black 
tongue,  it  is  grand.  No  matter  what  the  disease,  unless  flux 
or  cancer  of  the  stomach,  instead  of  drugs  which  often  kill, 
give  this  and  in  most  cases  it  will  put  them  on  their  feet  in 
a  few  days.     There  is  too  much  calomel  and  opium  given 


SECRET   SYSTEMS  EXPOSED.  327 

in   states  of  low  vitality;  they  destroy   what   little   vitality 
remains,    Instead,  this  gives  prodigious  vigor  so  quickly. 

"In  many  diseases  apparently  beyond  the  reach  of  human 
skill,  when  all  hope  is  gone,  if  the  patient  can  swallow,  give 
this  remedy  and  you  will  be  astonished  and  delighted  and 
save  many  lives.  In  consumption,  if  the  cough  does  not 
yield  to  this  remedy,  give  one  drop  of  peppermint  oil  on 
sugar,  three  times  daily,  before  meals.  In  all  cases  except 
consumption,  use  alternate  extension  and  flexion  of  all  the 
muscles,  ten  minutes  each  day." 

I  have  not  used  this  compound,  nor  do  I  credit  the 
statements  made  in  its  favor.  It  is  given  here  as  a  striking 
example  of  the  extraordinary  claims  that  can  be  made  for 
a  common  remedy  for  the  purpose  of  exciting  interest  and 
promoting  its  sale. 

A  large  illustrated  circular,  the  size  of  a  small  news- 
paper, accompanied  these  formulae,  and  contained  many 
beneficial  results  follow  its  use,  I  would  be  pleased  to  hear 
of  them.— T.  D.  A. 


329 


GENITO  -  URINARY 
SPECIALTIES. 

Contributed  By  T.  W.  Williams,  M.  D., 
Milwaukee,  Wis. 


NON  SURGICAL  TREATMENT  OF  THE  PROSTATE. 

Affections  of  the  prostate  are  more  common  than  is 
generally  supposed.  I  have  frequently  been  consulted  by 
patients  for  supposed  stricture,  bladder  or  kidney  troubles 
which  upon  examination  proved  to  be  enlargement  of  the 
prostate.  In  his  "Clinical  Lectures  on  Diseases  of  the  Uri- 
nary and  Generative  Organs,"  Sir  Henry  Thompson  asserts 
that  a  digital  examination  of  men  over  fifty-five  will  disclose 
the  fact  that  at  least  one-third  have  more  or  less  enlargement 
of  the  prostate.  It  is,  in  fact,  a  disease  almost  peculiar  to 
middle  and  advanced  life. 

The  points  of  special  clinical  importance  in  reference  to 
the  anatomy  of  the  prostate  are,  that  when  the  fore  finger 
is  introduced  well  up  into  the  rectum  the  healthy  prostate 
is  felt  in  the  median  anterior  line  as  a  body  about  one  and 
a  half  inches  long  and  nearly  as  broad,  lying  about  an  inch 
and  a  half  beyond  the  internal  sphincter  ani.  The  vesiculae 
seminales  lie  beyond  it,  with  the  vasa  efferentia  opening 
into  that  portion  of  the  urethra  surrounded  by  it.  In  all 
chronic  urinary  troubles  the  practitioner  should  not  fail  to 
make  a  digital  examination  of  the  prostate,  as  it  will  often 
yield  valuable  diagnostic  indications. 

The  two  principal  factors  in  the  production  of  pros- 
tatic diseases  are  previous  gonorrhoea  and  sexual  abuse. 
What  Hufeland  terms  "moral  onanism,"  or  that  continued 
state  of  erethysm  of  the  sexual  system  produced  by  the  mind 


330  GENITO-URINARY. 

dwelling  upon  lewd  objects, — frequently  prolonged  excite- 
ment of  the  organs  without  physiological  gratification, — in 
fact  an)-  cause  inducing  congestion  or  plethora  of  the  gland, 
lays  the  foundation  for  future  chronic  enlargement.  Gon- 
orrheal inflammation  affects  the  prostate  iri  much  the  same 
way  that  it  does  the  testicle,  but  much  more  frequently, 
although  seldom  recognized  on  account  of  its  location.  Con- 
sequently those  who  have  been  much  addicted  to  venereal 
indulgence  in  their  younger  days,  become  the  victims  of 
prostatic  disease  in  later  life.  The  hypertrophy  may  be 
either  acute  or  chronic.  The  acute  form  is  usually  a  result 
of  extension  of  the  urethral  inflammation  of  gonorrhea  and 
need  not  engage  our  attention' for  the  purpose  of  this  essay. 
Chronic  enlargement  may  be  due  to  a  simple  increase  in  the 
size  of  the  gland,  from  previous  inflammation,  or  congestion 
from  erotic  excitement;  or  it  may,  and  frequently  does, 
arise  from  scrofulous  calcareous,  or  tubercular  deposits  in 
its'  substance ;  and  finally  it  may  be  due  simply  to  growth 
from  increased  nutrition  following  an  increased  blood  sup- 
ply, accompanied  by  narrowing  of  the  return  veins.  After 
death,  in  this  latter  form,  an  enlargement  of  the  blood  vessels 
similar  to  that  in  abnormal  growths,  has  been  observed.  We 
are  usually  able,  by  careful  investigation,  to  diagnose  the  par- 
ticular form  of  enlargement  with  which  we  have  to  deal. 

The  degree  of  trouble  arising  from  enlarged  prostate 
depends  upon  its  character.  The  lateral  lobes  may  be  greatly 
enlarged  without  producing  much  inconvenience;  but  even 
£  ver)''  slight  enlargement  of  the  median  lobe,  forming  as  it 
does  the  floor  of  the  prostatic  portion  of  the  urethra,  will 
produce  more  or  less  urinary  troubles.  I  have  sometimes 
found  an  enormous  enlargement  of  the  lateral  lobes  in 
patients  who  had  experienced  hardly  any  symptoms  refer- 
able to  the  prostate ;  but  on  the  other  hand  I  have  frequently 
had  patients  who  had  become  regular  "urinary  cranks,"  in 
whom  the  enlargement  of  the  median  lobe  could  scarcely  be 
detected  by  the  most  careful  digital  examination.  The  reason 
is  that  the  slightest  elevation  of  the  floor  of  the  prostate  acts 


PROSTATE)— DR.    Wltl/IAMS.  33I 

as  a  dam  to  hold  the  water  back,  necessitating  stronger 
expulsive  efforts,  and  eventually  more  or  less  vesical  tenes- 
mus. 

Most  of  the  evils  resulting  from  hypertrophy,  as  Dr. 
Godlee  has  pointed  out,  "depend  upon  the  fact  that  the 
bladder  is  never  emptied;  it  is  essential,  therefore,  that  the 
patient's  power  in  this  respect  should  be  ascertained  with- 
out delay  by  catheterization,  and  if  it  be  discovered  that  a 
certain  amount  of  residual  urine  remains,  he  should  be  taught 
to  pass  the  instrument  himself,  and  directed  to  do  so  once  a 
day.  Secondly,  cystitis  has  often  been  caused  by  setting  up 
putrefaction  of  the  urine."  Urinary  retention  is  very  apt  to 
produce  cystitis,  not  only  on  account  of  decomposition  of  the 
urine,  but  from  infection  conveyed  into  the  bladder  by  cathe- 
terization. The  odor  of  the  urine  in  chronic  prostatic  disease 
is  quite  characteristic,  on  account  of  ammoniacal  decomposi- 
tion. 

The  prominent  symptoms  are:  Difficulty  in  emptying 
the  bladder,  the  urine  escaping  in  driblets ;  a  frequent  desire 
to  pass  water,  especially  nights  and  mornings ;  the  charactei 
of  the  urine  is  usually  unchanged,  and  there  may  be  some 
slight  pain  before  passing  it,  but  usually  none  afterwards. 
These  are  the  premonitory  signs  of  hypertrophy;  later,  the 
patient  finds  it  difficult  to  hold  water ;  the  desire  to  pass  it  is 
imperative,  and  must  be  immediately  attended  to.  It  is  no 
unusual  mistake  for  physicians  whose  attention  has  not  been 
particularly  called  to  the  subject  to  ascribe  these  symptoms 
to  bladder  or  kidney  troubles  and  prescribe  accordingly. 

Chronic  Prostatitis  is  one  of  the  most  frequent  causes 
of  sexual  and  urinary  troubles  in  men  of  all  ages,  particularly 
between  twenty-five  and  forty-five.  Its  symptoms  resemble 
those  of  stone  in  the  bladder.  These  are :  A  frequent  desire 
to  urinate,  a  feeling  of  weight  and  heat  in  the  perineum,  and 
a  pain  extending  the  whole  length  of  the  passage.  At  times 
a  few  drops  of  blood  will  follow  the  water,  or  the  water  will 
be  bloody  from  rupture  of  the  peripheral  vessels,  and  gener- 
ally the  patient  suffers  from  frequent  nocturnal  emissions. 


332  GENITOURINARY. 

The  urine  is  cloudy,  and  deposits  a  muco-purulent  mass 
after  standing  awhile.  It  is  frequently  met  with  as  a  sequel 
of  gleet  which  has  extended  to  the  prostatic  portion.  There 
is  also  more  or  less  complaint  in  regard  to  the  urine,  which 
feels  hot,  with  a  slight  smarting  or  stinging  sensation  after 
passing;  and  there  is  often  a  feeling  as  if  the  bladder  was  not 
entirely  evacuated,  which  is  true,  as  a  very  slight  enlarge- 
ment of  the  floor  or  middle  portion  of  the  gland,  as  previously 
remarked,  interferes  with  the  complete  emptying  of  the  blad- 
der, and  causes  the  last  drop  to  dribble  away  after  the  stream 
of  urine  has  ceased. 

Hyperaesthesia  of  the  Prostate  is  a  condition  frequently 
encountered  among  young  and  middle  aged  men.  Its  princi- 
pal symptom  is  the  oozing  out  of  a  thin  transparent  mucus, 
resembling  the  white  of  an  egg,  sufficient  to  keep  the  meatus 
moist  and  sticky.  In  traveling  over  the  alkali  plains  some 
years  ago,  I  noticed  that  all  the  mares  in  the  party  suffered 
from  a  similar  discharge  from  drinking  the  alkaline  waters, 
and  plains-men  informed  me  that  as  a  result  of  the  continual 
"spewing,"  they  became  weak  and  emaciated.  The  glairy, 
mucous  secretion  that  oozes  out  as  a  result  of  sexual  desire 
in  both  sexes,  seems  to  be  of  the  same  character — a  product 
of  the  glands  of  Bartholine  in  the  female,  of  the  prostate  in 
men — seemingly  a  provision  of  nature  for  "oiling  up  the 
machinery"  preparatory  to  the  first  act  in  the  transmission  of 
life.  The  discharge  itself  is  quite  innocent  in  character,  being 
simply  an  increased  secretion  of  the  gland ;  but  it  is  usually 
very  annoying,  and  alarms  the  patient  who  mistakes  it  for 
seminal  fluid.  A  peculiarity  of  prostatorrhea,  as  the  trouble 
is  usually  called,  is  that  on  straining  at  stool,  large  quantities 
of  this  discharge  will  escape,  amounting  sometimes  to  a  table- 
spoonful  or  more.  After  prolonged  ungratified  sexual 
excitiment,  to  which  the  trouble  is  almost  wholly  due,  it  will 
mingle  with  the  urine,  sometimes  to  such  an  extent  as  to  give 
it  a  milky  appearance.  Such  symptoms  are  very  alarming 
to  the  laity  as  a  rule,  and  render  them  an  easy  prey  for  the 


PROSTATE — DR.    WILLIAMS.  333 

quack,  who  has  no  difficulty,  usually,  in  convincing  his  vic- 
tim that  he  is  suffering  from  a  bad  case  of  spermatorrhea ; 
and  still  less  in  speedily  relieving  him  of  it  by  the  use  of  the 
following  injection,  two  or  three  times  a  day: 

3£     Zinc  sulphate gr.  xv. 

Morphine    sulphate    gr.  ij- 

Rose  Water fl.  o  VJ- 

A  small  quantity  of  this  solution,  about  a  drachm,  is  to 
be  injected  twice  a  day  by  the  physician,  with  a  small  hard 
rubber  syringe  having  a  silver  nozzle  long  enough  to  reach 
the  prostate,  drop  by  drop,  the  process  taking  about  five 
minutes.  Or  the  bulb  catheter  syringe,  described  further  on, 
may  be  used. 

Prostatorrhea,  not  being  a  germ  disease,  yields  readily 
to  mild  astringent  washes,  like  the  above,  followed  by  a 
urethral  crayon  of  similar  composition,  with  the  addition  of 
hydrastis,  once  a  day  until  the  cure  is  complete.  Give  five 
grains  mono-bromid  of  camphor  three  times  a  day  as  an 
antaphrodisiac. 

Excellent  results  are  obtained  in  prostatorrhea  from 
local  applications  of  argyrol  ointment,  30  grains  to  the  ounce, 
made  with  Williams'  Urethral  Applicateur,  elsewhere 
described. 

Acute  Congestion  of  the  Prostate  is  an  alarming  acci- 
dent of  hypertrophy  to  which  sufferers  with  the  latter  affec- 
tion are  subject  as  the  result  of  indiscretions  in  diet,  drink- 
ing, exposure  to  cold,  or  other  apparently  trivial  causes. 
Its  symptoms  are:  sudden  and  complete  retention  of  urine, 
accompanied  by  bloody  urine.  An  increased  temperature, 
quick  pulse,  and  more  or  less  pain  and  uneasiness- in  the 
region  of  the  bladder.  If  the  urine  is  not  speedily  evacu- 
ated through  the  catheter,  putrefaction  ensues,  the  tongue 
becomes  dry  and  covered  with  a  brown  coat,  the  pulse 
becomes  faster  and  weaker,  and  the  patient  sinks  into  a 
typhoid  condition,  which  may  end  fatally.  Old  men  are 
more  liable  to  these  attacks  than  young  men. 


334  GENITOURINARY. 

The  treatment  of  such  cases  is  conducted  upon  general 
principles.  A  brisk  saline  cathartic  should  be  administered 
at  once,  (a  teaspoonful  each  of  Epsom  and  Glauber  salts 
dissolved  in  a  glass  of  warm  water  is  best),  and  a  hypoder- 
mic injection  of  ]/\  grain  sulph.  morphia,  repeated  if  neces- 
sary in  half  an  hour,  administered.  Internally  I  give  ^4 
grain  solid  extract  hyoscyamus,  which  has  a  special  action 
on  the  neck  of  the  bladder,  or  its  equivalent  of  the  fluid 
extract,  or  alkaloid,  hyoscyamine,  every  hour  until  the 
patient  is  brought  under  the  influence  of  the  combined 
opiates,  greatly  facilitating  the  introduction  of  the  soft 
catheter.  It  is  of  the  utmost  importance  to  prevent  decom- 
position of  the  urine  as  the  chief  danger  of  congestion  is  due 
to  this  cause.  For  this  purpose,  the  urine  must  be  evacuated 
and  the  bladder  washed  out  with  an  antiseptic  alkaline  solu- 
tion.    The  following  answers  the  purpose  admirably : 

R     Sodium  Carb 5  ij . 

Acid  Boracic 5  j . 

Sodium  Chorid 3  ij. 

Aqua   O  ij. 

M.     Filter. 

SPECIFIC  TREATMENT.  In  the  treatment  of  dis- 
eases of  the  prostate  gland,  I  have  obtained  the  most  satisfac- 
tory results  from  the  local  application  of  medicaments 
directly  to  the  prostatic  portion  of  the  urethra.  Practical 
experience  has  demonstrated  that  the  use  of  escharotics  for 
this  purpose  should  be  discouraged  on  account  of  their  liabil- 
ity to  leave  hardened  cicatrices,  which  interfere  with  the 
normal  functions  of  the  organs.  The  local  treatment  consists 
of  alterative  and  antiphlogistic  applications  directly  to  the 
prostate  by  means  of  the  Urethral  Applicateur  hereafter 
described,  once  or  twice  a  week,  followed  during  the  intervals 
by  the  specific  local  and  internal  treatment,  to  be  described 
presently.  As  an  antiphlogistic  alterative  application,  I  have 
found  nothing  superior  to  the  combination  of  Ung.  hydrarg. 


PROSTATE- — DR.    WIU<IAMS.  335 

per  nit.  and  cocaine.  It  is  prepared  by  rubbing  up  ten  grains 
of  cocaine  with  four  ounces  of  the  mercurial  preparation. 

I  have  used  this  preparation  in  my  special  practice  for 
a  number  of  years  with  the  most  gratifying  results.  I  employ 
the  Urethral  Applicateur,  charging  the  reservoir  with  the 
particular  ointment  decided  on  for  the  case.  [See  note  at  the 
end  of  this  article] . 

Passing  the  instrument  down  to  the  prostatic  portion  of 
the  urethra,  the  ointment  is  deposited  by  a  turn  of  the  screw 
plunger.  I  then  withdraw  the  instrument,  and  the  patient 
goes  about  his  business,  as  the  operation  causes  no  suffering, 
and  only  a  slight  smarting,  which  passes  off  in  a  few  minutes. 
I. repeat  these  operations  about  once  a  week,  sometimes  twice, 
and  it  is  seldom  necessary  to  continue  them  longer  than  from 
six  to  twelve  weeks.  The  effect  is  not  only  gratifying,  but 
immediate.  Patient  and  physician  are  not  discouraged  by 
waiting  too  long  for  tangible  results.  I  have  often  had 
patients  apply  for  treatment  who  had  been  under  the  care  of 
physicians  of  unquestionable  skill  for  months  without  appre- 
ciable benefit.  In  nearly  all  there  was  more  or  less  trouble 
of  one  kind  or  another  with  the  urine.  Yet  frequently  a 
single  application  to  the  prostate  has  made  a  marked  change 
in  lessening  the  urinary  trouble,  and  checking  seminal  emis- 
sions. 

I  follow  the  mercurial  application  in  twenty-four  or 
thirty-six  hours,  with  a  local  application  of  a  fresh  solution 
of  the  adrenals  of  the  sheep,  (suprarenal  capsules),  every 
other  day,  applying  it  with  a  catheter  syringe,  and  also 
administer  a  five  grain  tablet  of  desiccated  suprarenals  three 
or  four  times  a  day,  alternating  it  in  most  cases  with  a  five 
grain  tablet  of  desiccated  prostate  gland,  or  thyreoid,  if  of 
strumous  origin,  as  explained  later  on.  In  using  the  adrenal 
solution,  all  that  is  necessary  is  a  urethral  syringe,  with  a 
silver  nozzle  of  sufficient  length  to  reach  the  bladder ;  an 
ordinary  soft  catheter  with  a  bulb  attached,  like  that  of  a 
"dropper,"  but  larger,  answers  every  purpose.  Such  a 
syringe  is  easily  extemporized  by  cutting  off  half  the  nozzle 


33^  GENITOURINARY. 

of  a  soft  rubber  ear  syringe,  inserting  a  piece  of  glass  tube 
and  passing  over  this  a  soft  catheter,  about  six  inches  long. 
The  catheter  is  carried  down  until  it  enters  the  bladder, 
and  then  is  withdrawn  until  its  point  lies  midway  the  pros- 
tatic portion  of  the  urethra,  and  the  solution,  to  the  extent 
of  from  thirty  drops  to  a  drachm,  is  pressed  out  into  the 
canal  drop  by  drop,  allowing  time  for  complete  saturation  of 
the  canal,  or  from  ten  to  fifteen  minutes.  This  briefly  out- 
lines the  specific  treatment,  which  will  afford  speedy  and 
permanent  relief  in  the  large  majority  of  all  cases  of  genuine 
prostatic  diseases,  whether  the  symptoms  are  due  to  hyper- 
trophy, acute  or  chronic  inflammation;  otherwise  the  case  is 
handled  on  general  principles,  according  to  the  indications 
present,  stimulating  the  liver,  if  inactive,  and  keeping  the 
bowels  open  at  the  same  time  with  a  teaspoonful  of  sodium 
phosphate  dissolved  in  a  half  pint  or  more  of  warm  water 
every  night  on  retiring,  and  looking  after  the  digestive 
organs  if  impaired.  Xo  other  laxative  meets  these  indica- 
tions in  prostatic  diseases  quite  as  well  as  the  phosphate  of 
soda. 

In  conjunction  with  the  general  course  of  treatment  out- 
lined above,  I  prescribe  in  most  cases,  rectal  suppositories 
and  urethral  crayons  composed  of  one  ounce  each  of  Euro- 
phen.  Aristol  and  Sulphonal  to  28  ounces  of  cocoa  butter. 
with  2  ounces  beeswax  to  give  the  requisite  degree  of  firm- 
ness, moulded  into  35  grain  rectal  cones  and  15  grain  crayons. 
A  crayon  and  a  suppository  are  used  alternately  every 
twelve  hours,  and  give  us  the  specific  alterative  effects  of 
these  drugs  on  the  enlarged  gland,  combined  with  an  anal- 
gesic effect  without  the  disadvantages  attendant  upon  the 
local  application  of  the  original  preparations  of  iodoform 
and  iodine. 

K      Cocoa   Butter    ( Huyler's") 5  xxviij. 

Bee's   Wax.    white 5  ij. 

Europhen. 

Aristol, 

Sulphonal    aa  5   i. 


PROSTATE — DR.    WILLIAMS.  337 

Melt  the  cocoa  butter  in  a  water  bath  with  the  wax; 
stir  in  the  europhen,  aristol  and  sulphonal ;  stir  until  it  cools 
down  to  a  point  at  which  it  begins  to  thicken  but  still  runs 
freely,  and  pour  into  suppository  moulds  of  sufficient  size 
to  form  thirty-five  to  forty  grain  suppositories,  and  set  on  ice 
to  cool.  When  removed  from  the  moulds,  they  are  dusted 
with  lycopodium  and  each  one  is  wrapped  in  waxed  paper. 
Keep  in  a  cool  place  as  they  melt  at  body  temperature. 

The  urethral  crayons  are  moulded  from  the  same  mass, 
with  the  addition  of  one-half  ounce  hydrastine  hydrochlo- 
rate  (Merck)  to  the  above  quantity.  The  crayon  moulds 
are  bored  out  so  as  to  form  crayons  about  three  inches  long, 
three-sixteenths  of  an  inch  in  diameter  at  the  large  end, 
tapering  to  a  point.  The  materials  entering  into  them  render 
these  suppositories  and  crayons  quite  expensive,  but  they 
are  indispensable  in  the  specific  treatment  of  prostatic  dis- 
eases. 

The  solution  of  the  suprarenals  of  the  sheep  is  pre- 
pared by  macerating  six  grains  of  the  powdered  desiccated 
gland  in  a  teaspoonful  of  distilled  water  for  two  minutes, 
and  straining.  It  should  be  prepared  fresh  for  each  case 
and  used  immediately,  as  it  deteriorates  rapidly.  When 
properly  prepared  its  immediate  effect  is  to  blanch  red  and 
inflamed  mucous  membranes  in  one  minute,  as  may  be 
witnessed  in  its  application  to  the  eye  in  conjuctivitis. 
Applied  every  other  day  to  the  prostate  gland,  in  conjunc- 
tion with  the  other  treatment  given,  the  entire  gland  eventu- 
ally shrinks,  contracts  and  shrivels  up,  with  a  marked  amel- 
ioration of  all  the  symptoms. 

In  all  chronic  cases  of  prostatic  disease,  the  mucous 
membrane  of  the  bladder  is  in  a  condition  of  sub-acute 
inflammation,  with  more  or  less  urinary  derangement,  alka- 
line or  ammoniacal  urine,  etc.  Diuretic  treatment  is  very 
important  in  such  cases,  not  only  on  account  of  the  urinary 
trouble,  but  to  keep  the  urine  in  an  aseptic  condition.  Diu- 
retic preparations  with  a  special  tendency  to  the  bladder 
should  be  used.     For  this  purpose  I  employ  the  following 


33&  GENITOURINARY. 

tablet,  which  can  be  prepared  as  a  special  formula  by  any  of 
the  manufacturing  pharmacists.  I  may  add  that  it  is  one  of 
the  best  all  around  "Kidney  Pills"  extant. 

I£     Buchu, 

Para-Formaldehyde, 
Potassium  Nitrate, 

Triticum  Repens aa  gr.  j . 

Tr.    Digitalis V(l  j. 

Oil  Juniper TTt  ss. 

Mix.    Ft.  one  coated  tablet  or  pill. 

Sig.  One  or  two  according  to  the  exigencies  of  the 
case,  to  be  taken  every  four  or  six  hours,  with  a  glass  of 
water. 

RECAPITULATION. 

After  the  diagnosis  of  the  case  is  established,  the  blad- 
der having  been  evacuated  and  washed  out  if  necessary, 
apply  the  per  nitrate  ointment  (Ung.  Hydrarg.  Nitratis,  or 
Citrine  Oint.  U.  S.  P.)  at  once  and  commence  the  internal 
treatment.  Direct  the  patient  to  commence  immediately  with 
the  rectal  suppositories,  using  one  by  the  bowel  every  night 
at  bedtime.  The  third  day  after  the  operation,  he  is  to  use 
in  addition,  at  bedtime,  a  urethral  crayon,  repeating  it  every 
other  night.  Put  him  on  the  kidney  pills  at  once  and  direct 
him  to  use  one  of  the  adrenal,  or  one  of  the  prostatic  tablets, 
between  the  times  of  taking  the  kidney  pills,  alternating 
them,  taking  a  prostatic  tablet  one  time  and  an  adrenal  the 
next.  He  should  call  the  next  day  after  the  application  of 
the  per  nitrate  ointment,  for  an  application  of  the  solution 
of  the  suprarenals,  and  every  other  day  thereafter.  Once  a 
week  will  be  often  enough  for  the  per  nitrate  applications. 

If  you  have  reasons  to  suspect  that  the  hypertrophy  is 
of  strumous  origin,  or  that  state  of  heredity  predisposing  to 
goitre,  enlarged  glands  of  the  neck,  etc.,  substitute  five 
grain  tablets  of  the  thyreoid  extract  from  the  sheep,  for  the 
desiccated  prostate  gland  extract.     It  is  your  sheet  anchor 


PROSTATE DR.    WILLIAMS.  T)39 

in  such  cases,  but  quite  useless  in  prostatic  enlargements 
from  any  other  cause.  All  of  the  animal  extracts  used  are 
from  the  Armour  laboratories. 

This  is  the  regular  routine  treatment,  but  the  experi- 
enced physician,  taking  it  as  a  basis,  will  no  doubt  be  able  to 
modify  and  vary  it,  according  to  the  necessities  and  circum- 
stances of  each  individual  case.  Specific  instructions  to 
cover  all  possible  points  that  may  arise  in  practice  would 
swell  this  article  to  the  proportion  of  a  large  volume. 

This  article  does  not  include  the  surgical  treatment  of 
the  prostate  gland,  which  should  be  a  dernier  ressort.  After 
all  other  means  have  failed,  life  may  be  prolonged  in  com- 
parative comfort,  even  in  men  between  sixty  and  seventy, 
by  extirpation  of  the  gland. 

This  operation  has  been  carried  to  such  perfection  in 
late  years,  as  to  involve  comparatively  little  danger  of  life. 
I  very  much  prefer  the  perineal  route,  as  practiced  by  Dr. 
Alexander,  of  New  York,  to  the  English  supra-pubic  opera- 
tion. 

Note. — In  my  article  published  in  the  second  edition  of 
this  work  I  advised  the  use  of  the  Lallemande  porte  caus- 
tique  for  making  local  applications  to  the  prostate,  but  since 
then  I  have  perfected  the  urethral  applicateur,  which  is  much 
to  be  preferred,  and  which  is  fully  described  in  the  following 
chapter  on,  "A  New  Method  of  Treating  Disease  of  the  Male 
Urethra." 


34°  GENITOURINARY. 


A  NEW  METHOD  OF  TREATING  DISEASE  OF  THE 
MALE  URETHRA. 

The  paucity  of  suitable  surgical  appliances  for  treating 
the  male  urethra  has  always  been  an  obstacle  to  the  advance 
of  genito-urinary  surgery.  Since  Lallemande's  port  cans- 
iique  was  brought  to  the  attention  of  the  profession  in  1836, 
there  has  been  little  substantial  improvement  along  this  line. 

Lallemande's  instrument  consists  of  a  catheter-like 
canula,  provided  with  a  caustic  carrier  as  its  name  implies, 
in  which  was  an  elongated  depression,  or  cup  which  could 
be  drawn  into  the  canula  covering,  during  its  introduction, 
and  projected  when  the  portion  of  the  urethra  was  reached 
which  was  to  be  operated  on,  and  turned  around  once  or 
twice,  so  as  to  bring  the  caustic  in  contact  with  all  parts  of 
the  membrane.  The  cup  was  first  filled  with  crystals  of 
silver  nitrate  and  held  over  a  spirit  lamp  until  they  were 
fused  into  a  solid  mass. 

With  this  caustic-carrier,  Lallemande  cauterized  the 
caput  gallinaginis  about  once  a  week,  and  claimed  for  it  the 
most  brilliant  results  in  spermatorrhea  and  impotence.  Sub- 
sequently his  instrument  was  adopted  for  other  cauterant 
applications  to  the  deep  urethra  and  prostate  gland.  A  cer- 
tain amount  of  tactile  dexterity,  acquired  only  by  practice,  is 
required  to  handle  the  instrument  successfully,  and  even 
when  this  is  acquired,  it  is  rather  difficult  to  limit  the  cauter- 
ant action  at  will. 

Other  operators  have  failed  to  secure  the  wonderful 
results  obtained  by  Lallemande  with  his  method,  which  is 
possibly  due  to  the  fact  that  he,  as  the  inventor  of  the 
method,  was  an  enthusiast  unable  to  analyze  results  with 
impartiality.  Being  also  the  only  physician  of  renown  in  his 
time  who  made  a  specialty  of  sexual  weakness,  as  a  natural 
consequence,  as  Dr.  Vecki  remarks,  people  of  the  wealthy 


.MALE    URETHRA DR.     WILLIAMS.  34  l 

class  afflicted  or  imagining  themselves  afflicted  with  sexual 
debility,  flocked  to  him  from  far  and  near ;  and  as  the  larger 
proportion  of  those  seeking  medical  advice  for  functional 
forms  of  this  ailment  are  psychically  impotent,  it  is  possible 
that  Lallemande's  fame,  combined  with  the  great  renown  of 
his  method,  exerted  a  greater  curative  influence  upon  these 
neurasthenics  than  his  porte  caustiquc. 

The  slow  and  painstaking  physicians  of  Germany,  dis- 
appointed in  being  unable  to  secure  Lallemande's  brilliant 
results,    rejected    his    method    entirely;    nevertheless,    most 
genito-urinary  surgeons  admit  the  value  of  cauterization  in 
spermatorrhea  and  impotence  due  to  organic  changes  in  the 
prostatic  urethra,  although  we  now  possess  a  better  instru- 
ment than  the  porte  caustique,  in  Williams'  Urethral  Appli- 
cateur,  and  a  superior  agent  to  lunar  caustic,  in  argyrol  and 
nitrate  of  mercury.     Cauterization  by  Lallemande's  method, 
especially  if  unskillfully  performed,  was  frequently  followed 
by  dysuria  and  bloody  urine  for  two  or  three  days,  and  some- 
times the  inflammation  was  so  intense  as  to  render  ice  bags 
to  the  perineum,  dieting,  bathing  and  a  regular  antiphlogistic 
regimen  necessary.     With  the  pernitrate  of  mercury  oint- 
ment, as  herein  recommended,  the  pain  is  slight,  lasting  only 
a  tew  minutes,  and  there  is  no  dysuria  after  the  first  passage 
of  water;  while  an  application  of  even  a  strong  ointment  of 
the  silver  preparation  known  as  argyrol,  is  absolutely  pain- 
less. 

One  serious  objection  to  the  application  of  solid  sdver 
nitrate  to  the  ejaculatory  ducts  and  colliculus  seminalis,  is 
its  tendency  to  form  chemical  combinations  with  the  tissues, 
and  unless  great  care  is  exercised,  it  is  liable  to  make  too 
deep  a  burn,  which  results  in  the  formation  of  cicatrical  tis- 
sue. This  accident  produces  a  patulous  condition  of  the 
ducts,  aggravating  rather  than  removing  spermatorrhoea. 

I  have  met  with  very  few  cases  in  which  protargol,  or 
some  of  the  other  silver  preparations,  or  the  ointment  of 
pernitrate  of  mercury,  U.  S.  P.,  has  not  given  equally  sjood. 


342  GENITOURINARY. 

if  not  better  results  than  nitrate  of  silver,  without  its  disad- 
vantages. 

I  attribute  this  to  the  fact  that  the  oleaginous  nature  of 
the  preparation  limits  its  caustic  action  to  the  surface  of  the 
tissues,  which  are  usually,  as  shown  by  the  endoscope, 
in  a  hyperaemic,  swollen  or  granular  condition.  By  thus 
acting  upon  the  surface  of  the  engorged  tissue,  its  morbid 
irritability  is  changed,  and  a  healthy  contraction  excited  in  it 
which  causes  it  to  empty  itself,  become  paler,  and  retain 
a  tonic,  energetic  action  until  its  normal  condition  is 
restored  by  subsequent  soothing,  healing  and  astringent 
applications. 

I  employ  it  almost  exclusively  in  operations  on  the  deep 
uicthra. 

The  latest  of  these  silver  preparations,  argyrol,  contain- 
ing 30  %  of  silver,  bids  fair  to  supersede  all  the  others.  A 
10  %  ointment  of  this  preparation  may  be  substituted  for  the 
pernitrate  of  mercury  ointment.    Prepare  as  follows  : 

^     Argyrol    grs.  xlviij . 

Lanum  3  vj. 

Olive    Oil 3  ij. 

Mix.    Ft.    Unguent. 

I  commenced  using  the  pernitrate  as  a  local  antiphlogis- 
tic and  cauterant  about  1882.  [See  the  Therapeutic 
Gazette,  June,  1885].  At  that  time  and  until  recently  I  used 
Lallemande's  porte  caustique  for  making  the  application,  by 
filling  the  cap  with  the  ointment  instead  of  with  fused  silver 
nitrate.  The  principal  objection  to  the  porte  caustique  for 
this  purpose  is  that  it  does  not  hold  a  sufficient  quantity  of 
the  ointment  for  the  various  purposes  of  such  an  instrument. 

More  recently,  however,  I  devised  a  Urethral  Appli- 
cateur,  which  I  have  not  only  found  very  much  better  for 
this  purpose,  but  also  for  treating  disease  of  the  urethra 
generally,  enabling  us  to  make  any  kind  of  medicinal  appli- 
cation to  that  canal  as  readily  as  if  it  were  an  external  mem- 
brane. 


MALE    URETHRA DR.    WILLIAMS. 


343 


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The  instrument  is  represented  by  the  subjoined  cut.  It 
consists  of  a  silver  or  heavily  plated  catheter-stem,  about 
seven  inches  long,  closed  at  the  distal  extremity,  and  per- 
forated with  1-32  holes,  which  screws  into  a  hard-rubber 
reservoir,  or  cup  to  contain  the  medicament.     A  hard-rubber 


344  GENITOURINARY. 

plunger  screws  into  the  top  of  the  reservoir  and  forces  the 
ointment  through  the  catheter.  It  is  introduced  into  the 
urethra  as  far  back  as  the  neck  of  the  bladder,  so  as  to  cover 
the  prostatic,  or  deep  urethra  and  colliculus  seminalis.  While 
steadying  the  instrument  with  the  thumb  and  forefinger  of 
the  left  hand  on  the  projecting  rim  of  the  reservoir,  the 
physician  by  making  a  turn  of  the  screw  plunger,  causes  the 
extrusion  of  the  medicament.  The  instrument  is  turned 
around  in  the  canal  once  or  twice  to  spread  the  ointment 
before  withdrawing  the  catheter. 

Cauterant,  antiphlogistic,  analgesic  and  astringent  appli- 
cations in  the  form  of  ointments,  are  readily  applied  to  the 
colliculus  seminalis  and  deep  urethra,  in  chronic  urethritis, 
stricture,  gleet,  spermatorrhea,  premature  emissio  seminis  in 
coitus,  dribbling  of  urine  from  loss  of  contractility  of  the 
canal,  prostatitis,  etc.  For  cauterizing  the  ejacnlatory  ducts 
and  caput  gallinaginis,  it  is  preferable  to  Lallemande's  porte 
caustique.  Acute  gonorrhoea  and  non-specific  urethritis  can 
be  most  effectually  treated  by  first  deadening  the  sensitive- 
ness of  the  canal  by  injecting  a  few  drops  of  a  one  or  two 
per  cent,  solution  of  Beta-eucaine  or  cocaine,  then  passing 
the  catheter  stem,  anointed  with  carbolized  sweet  oil,  down 
to  the  prostate,  and  extruding  the  medicament  as  the  instru- 
ment is  slowly  withdrawn,  thus  spreading  it  over  the  entire 
urethral  surface.  This  not  only  brings  it  in  contact  with 
every  part  of  the  affected  membrane,  for  a  longer  time  than 
injections,  but  keeps  the  inflamed,  granulated,  mattering 
surfaces  separated. — a  sine  qua  non  in  facilitating  the  healing 
process. 

The  Applicateur  gives  much  better  results  in  urethral 
disease  than  injections  or  crayons.  With  it  we  can  accom- 
plish more  in  chronic  cases  in  three  or  four  weeks,  than  we 
can  by  the  ordinary  methods  in  vogue  in  as  many  months. 
It  affords  a  wide  choice  of  remedial  agents.  There  is 
scarcely  any  cauterant.  antiphlogistic,  analgesic,  astringent, 
stimulant  or  healing  application  that  we  cannot  administer  to 
die  urethra  as  readilv  as  if  it  were  situated  externally.    Ung. 


MALE    URETHRA DR.     WILLIAMS.  345 

hydrarg.  nitrat.,  (preferable  as  a  cauterant  to  nitrate  silver), 
Ung.  hydrarg.,  oxide  of  zinc,  subnitrate  of  bismuth,  bole 
Armenian  (supposed  to  be  the  basis  of  "Injection  Brou," 
and  to  act  by  depositing  an  astringent  earthy  sediment  on  the 
canal  which  keeps  its  folds  separated),  hydrastis,  cocaine, 
morphia,  sulphate  of  zinc,  adrenalin  chloride,  (i-iooo)  aris- 
tol,  iodoform,  iodine,  salol,  ichthyol,  protargol,— in  fact  any 
and  all  of  the  ingredients  usually  employed  in  the  numerous 
urethral  crayons  on  the  market,  can  be  more  effectually  and 
safely  applied  with  this  instrument  in  the  form  of  oint- 
ments, using  lantim  (Merck)  and  olive  oil,  Ya  of  the  former 
to  YA  of  the  latter,  as  a  vehicle,'  the  adhesiveness  of  which 
retains  the  remedy  in  direct  contact  with  the  diseased  mem- 
brane for  a  long  time,  during  which  the  latter  is  separated 
and  distended,  affording  the  best  opportunity  for  the  exer- 
cise of  its  gonococicide  properties. 

In  the  treatment  of  Stricture  of  the  Urethra,  also,  the 
Applicateur  furnishes  a  valuable  addition  to  the  genito- 
urinary surgeon's  armenatarium.  I  have  observed  that  if  the 
applications  of  the  Ung.  hydrarg.  pernit.  are  repeated  every 
other  day  for  a  while,  the  patient  begins  to  pass  numerous 
shreds  in  the  urine,  caused  by  the  deadening  and  peeling  off 
of  the  epithelial  layer  of  the  mucous  membrane.  In  a  few 
instances  complete  casts  of  the  prostatic  urethra  have  been 
"shed"  in  this  way,  much  to  the  alarm  of  the  patient.  Thus 
it  is  possible  with  this  instrument  to  repair  a  diseased  urethra 
by  giving  it  a  new  lining,  as  it  were,  and  to  enlarge  the 
calibre  of  a  strictured  portion,  not  only  by  the  absorption  of 
the  layer  of  organized  lymph  deposited  beneath  its  surface, 
but  also  by  repeatedly  reaming  out  the  passage,  so  to  speak, 
by  causing  the  disorganization  of  one  almost  imperceptible 
layer  of  tissue  after  another.  In  none  of  my  cases,  so  far, 
have  I  observed  the  least  untoward  result  from  this  process. 

By  turning  the  Applicateur  around  once  or  twice,  and 
giving  the  screw  plunger  a  backward  turn,  the  little  ointment 
remaining  on  the  tube  will  never  noticeably  affect  the  anterior 
passage. 


34-6  GENITOURINARY. 

Lavage  of  the  urethra  with  water  as  hot  as  it  can  be 
borne,  impregnated  with  some  mild  antiseptic,  before  using 
the  Applicateur,  is  good  practice,  especially  in  acute  cases. 
The  deeper  creases  and  mucous  cavities  are  thus  thoroughly 
cleansed  and  the  ointment  has  a  more  direct  action.  The 
catheter  stem  of  the  Applicateur,  attached  to  a  rubber  bulb, 
makes  a  good  syringe  for  urethral  lavage.  Fill  the  bulb, 
pass  the  stem  down  to  the  neck  of  the  bladder,  and  slowly 
inject  the  water  which  wells  up  around  the  stem  and  flows 
out  at  the  meatus.  Repeat  the  operation  several  times. 
Avoid  injecting  the  bladder,  but  should  some  of  the  fluid 
enter  it,  it  will  do  no  particular  harm ;  there  is,  however,  no 
danger  of  this,  unless  the  stem  is  carried  too  deep. 

I  will  add  a  few  approved  formulae  of  the  different 
ointments  which  I  have  found  best  adapted  for  the  purposes 
indicated. 

FORMULAE. 

No.   i.     K     Ung.  hydrarg.  nitrat.  U.  S.  P.  .   5  j. 

Cocaine, 

Morphia  sulph aa.  gr.  ij. 

Mix  and  rub  together  thoroughly  in  a  glass  mortar. 
Preferable  to  nitrate  silver  as  a  cauterant  of  the  ejaculatory 
ducts  and  colliculus  seminalis  in  spermatorrhea,  impotence 
and  chronic  urethritis,  with  premature  emission  in  coitus, 
dribbling  of  urine,  frequent  desire  to  urinate,  etc. 

No.  2.     1^     Beechwood   creosote fl.  3  ss. 

Lanum   (Merck) 3  vj. 

Olive  oil 5  ij. 

Morphia  sulph   gr.  ij. 

Mix. 

In  gleet,  urethral  ulcers  and  chronic  urethral  troubles. 

No.  3.     1?     Ung.  hydrarg,  U.  S.  P. 

Ung.  bismuth  oxide aa  §  ss. 

Morphia  sulph   gr.  ij. 

Mix.     In  gonorrhea  and  gleet. 


FORMULAE — DR.    WILLIAMS.  347 

No.  4.     I?     Fl.  Ext.  Belladonna, 

Fl.  Ext.  Hyoscyamus aa  3  ss. 

Olive  oil 5  ij- 

Lanum   (Merck) o  vj. 

Mix.    In  chordee,  tenesmus  urina,  and  dysuria. 

No.   5.      ty     Iodine   gr.  xx. 

Alcohol   A-  3  ss- 

Glycerine    A-  ^  ij- 

Lanum   (Merck)    o  ]■ 

Mix.     Rub  the  iodine  first  with  alcohol  and  glycerine, 
and  then  with  the  wool  fat  until  thoroughly  mixed. 
In  hypertrophy  of  the  prostate,  as  a  resolvent. 

No.  6.   1^   Pyoktanin    (Blue) gr.  x. 

Lanum   (Merck) 5  vj. 

Olive  oil 5  ij. 

Mix.    In  acute  and  sub-acute  gonorrhea. 

No.  7.     fy     Largin    (Merck) gr.  xx-xxx. 

Lanum   (Merck) 5  vj. 

Olive  oil 5  ij. 

Mix.    Twice  daily  in  acute  and  sub-acute  gonorrhea. 

No.  8.     Iy     Ichthargan  (Merck)   gr.  ss. 

Glycerin 3  ij. 

Lanum   (Merck) 3  vj. 

Mix.    Twice  daily  in  acute  and  sub-acute  gonorrhea. 

Nos.  6,  7  and  8  should  not  be  exposed  to  the  light. 

* 

No.  9.     ty     Zinc  Sulphate gr.  ij. 

Lead  acetate gr.  iv. 

Bole   Armenian gr.  viij. 

Morphia  sulph gr.  ij. 

Glycerine 5  ij. 

Lanum   (Merck) 5  vj. 

Mix.    An  excellent  application  in  sub-acute  gonorrhea, 
after  subsidence  of  the  inflammatory  stage,  twice  daily. 


34&  GENITOURINARY. 

No.   10.      K      Thiosinamine   (Merck) gr.  xx. 

Ether,  sulphuric q.  s. 

Glycerin 5  i j . 

Lanum  (Merck) 5  vj. 

Add  sufficient  ether  to  the  thiosinamine  to  dissolve  it, 
and  rub  with  the  glycerin  and  purified  wool  fat  until  thor- 
oughly mixed. 

Used  as  a  local  application  every  two  or  three  days,  as  a 
resolvent  in  stricture  and  hypertrophy  of  the  prostate  gland. 

All  urethral  troubles  progress  more  satisfactorily  when 
some  suitable  internal  treatment  is  combined  with  the  local 
applications.  In  gonorrhea  and  gleet  and  their  sequelae,  I 
have  never  found  anything  to  equal  a  capsule  of  sandal  oil, 
oil  of  cubebs,  gurjun  balsam,  and  benzoic  acid,  one  or  two 
to  be  taken  three  or  four  times  a  day.  It  is  a  good  plan  to 
take  a  digestive  tablet  in  connection  with  these,  or  any  oily 
capsules,  as  it  aids  their  digestion  and  absorption.  The 
digestive,  pepsin,  is  too  bulky  for  incorporation  into  the  cap- 
sule. 

These  capsules  can  be  prepared  by  any  competent  phar- 
macist, or  in  quantity  by  manufacturing  pharmacists. 

As  Varicocele,  Hydrocele  and  Hemorrhoids  are  fre- 
quently associated  with  Urethral  and  Prostatic  diseases,  and 
indeed  often  exist  as  causal  complications,  a  brief  consid- 
eration of  these  abnormalities  will  not  be  out  of  order. 
Beginning  with  Varicocele,  Hydrocele  and  Hemorrhoids  will 
follow  in  order. 


VARICOCELE — DR.    WILLIAMS.  349 


VARICOCELE. 

This  is  one  of  the  most  frequent  causal  complications  of 
spermatorrhea  and  impotence  with  which  we  have  to  deal. 

Varicocele  is  a  dilated  and  torturous  state  of  the  sper- 
matic veins.  It  generally  occurs  in  the  young,  and  is  almost 
always  confined  to  the  left  side,  because  the  left  vein  is  larger 
than  the  right,  and  more  indirect  in  its  course ;  but  mainly 
because  it  opens  into  the  renal  vein  at  a  right  angle,  thus 
preventing  a  free  flow  of  the  blood.  Whatever  may  be  the 
cause,  the  fact  is  that  the  walls  of  these  veins  give  way, 
become  relaxed,  as  it  were,  and  distended,  bulging  out  in 
places  into  little  pouches,  giving  the  vessels,  when  full  of 
blood,  a  knotty  appearance.  The  whole  vein,  in  old  cases, 
is  dilated,  enlarged,  tortuous,  cordy  and  knotty,  feeling  when 
taken  in  hand  like  a  bundle  of  angle  worms.  The  disease 
is  one  very  prevalent,  and  although  it  has  been  known  to 
exist  for  years  without  any  serious  results,  in  the  majority 
of  instances  it  results  in  wasting  of  the  testicle,  spermator- 
rhea and  impotence,  and  sooner  or  later  impairs  the  general 
health  by  nervous  irritation,  inducing  dyspepsia,  dragging 
sensations  in  the  groins,  lumbago,  pain  in  the  back,  general 
depression  of  the  system,  despondency,  gloomy  forebodings, 
etc.  The  irritation  produced  in  the  generative  organs  by 
variococele  acts  as  both  an  exciting  and  continuing  cause  of 
spermatorrhea,  and  retards  its  cure.  If  the  disease  is  only 
slight,  and  does  not  affect  the  general  health,  it  will  usually  be 
sufficient  to  use  such  palliative  treatment  as  may  be  necessary 
to  relieve  the  weight  and  dragging  sensations  and  produce 
contraction  of  the  enlarged  veins. 

This  consists  in  wearing  a  pelvic  appliance  constructed 
on  the  principle  of  an  elastic  truss,  with  two  soft  pads  to 


350  GENITO-URINARY. 

exert  a  moderate  pressure  upon  the  cords  at  the  external 
abdominal  ring,  and  thus  relieve  the  weight  of  the  superin- 
cumbent column  of  blood.  We  do  not  expect  to  effect 
a  radical  cure  of  the  varicocele  in  this  way,  but  to  overcome 
its  annoying  symptoms,  so  that  it  shall  not  interfere  with  the 
cure  of  the  seminal  trouble  invariably  associated  with  it. 

The  only  radical  cure,  however,  for  varicocele,  is  by  a 
slight  operation,  which  consists  of  ligating  the  diseased 
veins.  This  is  done  subcutaneously,  without  the  loss  of  a 
drop  of  blood,  and  without  interfering  with  the  spermatic 
artery  or  vas  deferens,  or  injuring  the  testicle  itself.  I  have 
operated  upon  several  hundred  cases  with  the  best  results, 
a  permanent  cure  being  affected  in  five  days,  during  which 
time  the  patient  has  to  remain  under  the  doctor's  care, 
although  not  confined  to  bed. 

The  technique  of  the  operation  is  as  follows  :  Grasp  the 
scrotum  on  the  affected  side,  the  patient  standing,  and  care- 
fully separate  the  varicose  veins  from  the  artery  and  vas 
deferens,  with  the  balls  of  the  fingers,  pushing  the  vas 
deferens,  which  is  easily  distinguished  by  its  hard,  cordy 
feel,  and  the  artery,  recognized  by  its  pulsations,  inwardly, 
and  keeping  them  separated  by  the  thumb  and  finger  of  the 
left  hand.  Then  pass  a  curved  needle,  threaded  with  a 
strong  silk  cord  through  the  scrotum,  between  the  vein  and 
the  separated  vas  and  artery,  and  draw  the  ligature  through. 

The  hold  on  the  scrotum  is  now  removed  and  the 
patient  directed  to  lie  on  the  operating  chair.  Then  by  taking 
the  scrotum  in  the  hands,  leaving  the  ligature  in  the  wound, 
you  can  bring  the  openings  on  each  side  of  the  scrotum, 
through  which  the  needle  passed,  exactly  opposite  each  other. 
Then  pass  the  needle  back  from  behind  forward,  through  the 
same  holes,  but  the  needle,  which  should  be  curved,  is  made 
to  return  on  the  opposite  side  of  the  veins  to  that  traversed 
in  its  first  passage,  which  encloses  the  veins  in  a  loop,  where 
it  is  drawn  through.  The  two  ends  of  the  cords  are  now 
tied  firmiv  with  a  single  knot,  and  then  tied  in  a  tight  double 
knot  over  a  cork,  and  the  operation  is  complete.    The  pain  is 


varicocele; — dr.  wiujams.  351 

sharp  and  sudden,  but  only  for  a  few  seconds,  as  the  parts 
are  speedily  deadened,  and  the  use  of  chloroform  is  unneces- 
sary, and  even  objectionable,  its  after  effects  being  more  dis- 
agreeable than  those  of  the  operation.  The  point  of  ligation 
is  about  two-thirds  the  length  of  the  scrotum  from  the  bot- 
tom ;  i.  e.,  at  the  bottom  of  the  upper  third  of  the  bag. 

I  am  in  the  habit  of  having  patients  come  to  my  office 
for  the  operation,  and  returning  home.  They  are  directed 
to  keep  quiet,  but  are  not  confined  to  the  bed.  On  the  fifth 
day,  by  which  time  there  is  thorough  union  of  the  inner  coats 
of  the  veins  at  the  point  of  ligation,  effecting  occlusion  of  the 
mass  of  veins;  the  ligature  is  removed,  and  the  wound 
dressed  with  antiseptic  gauze.  The  operation  is  followed  by 
some  swelling  and  soreness  of  the  testicle,  for  which  nothing 
more  is  required  than  a  cooling  lead  and  laudanum  lotion, 
but  care  must  be  exercised  that  the  bowels  are  kept  open 
daily  with  some  saline  laxative.  Complete  absorption 
of  the  mass  is  effected  in  about  a  month,  during  which 
time  a  suspensory  is  worn.  Great  care  must  be  used  not  to 
include  either  the  artery  or  vas  deferens  in  the  ligature.  This 
has  happened  to  me  once  or  twice  with  the  result  of  final 
atrophy  of  the  testicle. 

This  operation  effects  a  complete  and  radical  cure  of 
the  varicocele,  and  it  is  often  advisable  for  its  psychical  effect 
upon  the  patient,  aside  from  any  absolute  surgical  necessity. 
Patients  with  varicocele  .are  generally  monomaniacs  on  the 
subject,  and  are  reduced  to  a  state  of  hypochondria  by  worry- 
ing about  their  condition.  The  moment  they  are  operated  on 
they  drop  this  pall  of  gloom  and  anxiety  like  an  acursed 
mantle  and  regain  their  natural  moods.  I  have  had  them 
come  hundreds  of  miles,  fully  determined  to  submit  to  cas- 
tration ;  but  after  being  operated  on  for  varicocele,  they 
would  return  in  that  normal  state  of  mind  that  impels  a  man 
to  matrimony. 

The  mere  occlusion  of  the  varicose  veins  does  not,  how- 
ever, remove  the  relaxed  and  elongated  scrotum.     To  effect 


352  GENITOURINARY. 

this  very  desirable  object  and  avoid  the  necessity  of  wearing 
a  suspensory,  the  following  extension  of  the  operation  is 
employed. 

After  having  separated  the  varicose  veins  from  the  rest 
of  the  cord,  as  already  described,  and  passing  the  ligature 
through  the  scrotum,  the  latter  is  slit  up  in  front  about  one 
and  a  half  inches  above,  and  the  same  distance  below  the 
puncture  laying  open  the  tunica  vaginalis  testis  and  exposing 
the  cord.  Or  this  may  be  done  first,  and  the  veins  isolated 
and  ligated  afterwards.  This  method  is  best  with  inexperi- 
enced operators,  as  they  can  then  more  easily  separate  the 
veins.  I,  however,  prefer  separating  them  first.  The  lower 
end  of  the  slit  is  then  brought  up  and  attached  to  the  upper 
end  of  the  slit,  by  a  suture;  the  slit  then  appears  to  run 
horizontally  across  the  scrotum,  instead  of  perpendicularly. 
The  cut  edges  of  the  wound  are  next  united  by  interrupted 
sutures,  and  the  ends  of  the  ligating  cord  brought  outside  and 
left  about  three  inches  long.  This  has  the  effect  of  shortening 
the  scrotum,  so  that  it  forms  a  natural  suspensory  for  the 
testicles.  As  in  the  former  operation,  the  sutures  and  cord 
are  removed  from  the  fifth  to  the  sixth  day,  according  to  the 
condition  of  adhesion.  Neither  operation  is  attended  with 
any  special  danger  or  serious  after  effects,  if  properly  per- 
formed, and  gives  that  perfect  satisfaction  accorded  all  suc- 
cessful surgical  procedures. 


HYDROCELE — DR.    WILLIAMS.  353 

HYDROCELE. 
An  Occasional  Complication  of  Sexual  Debility. 
This  is  one  of  those  nondescript  diseases  that  comes,  no 
man  knoweth  whence.  It  is  simply  an  accumulation  of 
serous  fluid  in  the  tunica  vaginalis  and  its  treatment  is  so 
simple  that  it  scarcely  rises  to  the  dignity  of  a  specialty.  In 
fact,  all  that  is  necessary  is  to  evacuate  the  fluid,  of  which 
there  is  usually  ten  or  twelve  ounces,  with  a  trocar,  and, 
after  withdrawing  the  trocar,  inject  into  the  sac,  through 
the  canula,  an  irritating  fluid  that  will  set  up  sufficient 
inflammation  to  destroy  the  secreting  function  of  the  mem- 
brane. For  this  purpose  a  variety  of  substances,  from  milk 
or  salt  water,  to  iodine  and  carbolic  acid,  have  been  success- 
fully employed.  Iodine  seems  to  be  the  favorite  with  most 
surgeons,  from  a  half  drachm  to  a  drachm,  mixed  with  an 
equal  quantity  of  alcohol  or  water  being  thrown  into  the 
sac.  But  in  my  experience  it  often  fails  to  cure,  especially 
in  old  cases,  with  thickened  membrane.  Any  of  the  hernial 
fluids  may  be  used  in  the  same  way.  Whatever  fluid  is 
employed,  after  injecting,  the  bag  should  be  taken  between 
the  hands  and  massaged,  as  a  washerwoman  would  wash  a 
dishcloth,  to  bring  the  fluid  in  contact  with  all  parts  of  the 
membrane.  The  operation  is  followed  by  considerable  swell- 
ing and  soreness  for  a  week  or  ten  days,  the  more  the  better, 
and  after  it  subsides,  the  cure  is  usually  complete.  How- 
ever, if  the  fluid  accumulates  again,  the  operation  must  be 
repeated.  The  formula  which  follows  is  one  of  the  most 
satisfactory  fluids  for  hydrocele,  for  the  reason  that  it  pro- 
duces little  or  no  pain  at  the  time  of  the  injection,  although 
it  gets  in  its  work  about  the  third  day. 
1$     Guaiacol, 

Creosote aa.  TH,  i j . 

Zinc  Sulphate   gr.  ij. 

Ext.  Hamamelis,  Dist, 

Glycerine,  C.  P aa  fl.  3  j. 

M.     Sig.     After  evacuating,  inject  into  the  sac,  and 


354  GENITOURINARY. 

knead  the  scrotum  between  the  knuckles  so  as  to  ensure  its 
reaching  the  upper  part  of  the  cavity.  The  following  for- 
mula is  a  good  one,  in  my  experience. 

I£      Carbolic    Acid n\  xc. 

Ext.  Hamamelis,  Dist., 

Distilled    water    aa  fl.  5  vj. 

M .  Sig.  Of  this  mixture  take  20  minims ;  tinct.  iodine, 
20  minims ;  fluid  extract,  quercus  alba,  20  minims ;  glycerine, 
20  minims;  distilled  water  sufficient  to  make  4  drachms. 
Inject  the  whole  of  it  into  the  sac,  massage,  and  squeeze  it 
out. 

The  after  treatment  consists  simply  in  keeping  quiet  a 
few  days,  and  suspending  the  scrotum  until  the  swelling  and 
soreness  subside. 


HEMORRHOIDS. 


This  subject  is  considered  here  by  reason  of  the  frequent 
association  of  hemorrhoids  with  sexual  debility  as  a  compli- 
cation, and  a  frequent  cause  of  spermatorrhea  from  trans- 
mitted irritation.  For  this  reason  they  frequently  require 
the  attention  of  the  Genito-Urinary  specialist. 

Much  has  been  written  in  medical  books  about  the 
causes  of  hemorrhoids;  biologists  assert  that  it  is  a  weak 
spot  left  in  the  evolution  of  man  from  a  four  footed  animal, 
and  that  it  never  occurs  among  the  lower  animals, — the 
lapsus  natura  consisting  in  the  fact  that  the  superior  hemor- 
rhoidal veins  become  constricted  where  they  pass  through 
slits  or  openings  in  the  muscular  wall,  obstructing  the  pas- 
sage of  the  blood,  etc.  It  is  true  that  hemorrhoids  frequently 
result  from  mechanical  pressure  on  the  veins,  as  in  preg- 
nancy;  but  it  is  incorrect  to  say  that  constipation  is  one  of 
the  most  prolific  causes  of  hemorrhoids.     Constipation  rarely 


HEMORRHOIDS DR.    WILLI  AMS. 


355 


produces  hemorrhoids,  which  are  the  direct  result  of  obstruc- 
tion of  the  portal  circulation,  of  which  constipation,  as  well 
as  piles,  is  a  symptom.  The  congestion  and  torpidity  of  the 
biliary  circulation  which  causes  constipation  also  causes  piles 
by  damming  up  and  obstructing  the  passage  of  the  blood 
through  the  hemorrhoidal  veins. 

If  my  theory  is  correct,  that  hemorrhoids  are  simply  a 
painful  manifestation  of  obstruction  located  in  the  portal 
system,  there  is  never  any  actual  necessity  for  operating, 
although  the  relief  is  more  prompt  if  we  open  the  largest  of 
the  tumors  and  turn  out  the  clot  of  black  blood  we  shall  find 
there  in  external  and  constricted  internal  piles. 


"A  Bad  Case  of  Piles." 

In  this  illustration  eight  tumors 
are  shown  in  a  cluster  around  the 
anus.  Usually,  however,  there  are 
not  more  than  two  or  three. 


TREATMENT. 

The  quickest  and  easiest  method  of  getting  rid  of  hem- 
orrhoids is  a  slight  operation  which  I  prefer  to  the  injection 
treatment. 

My  method  is  as  follows :  Apply  a  piece  of  cotton  satu- 
rated with  a  io  %  solution  of  eucaine  or  cocaine  to  the  tumor 


356  GENITOURINARY. 

until  its  sensibility  is  deadened.  Now  slit  up  a  few  of  the 
largest  tumors  with  a  lancet  and  turn  the  clot  out;  then 
swab  out  with  equal  parts  of  95  %  carbolic  acid  and  glycer- 
ite  of  tannin;  follow  this  with  an  alcohol  swabbing;  apply 
a  sterile  pad  of  cotton  or  gauze,  kept  in  place  by  a  T  bandage. 

For  the  purpose  of  destroying  sensibility,  the  following 
modification  of  Schleich's  infiltration  anesthetic  solution' 
which  can  be  injected  around  and  over  the  tumor,  will  per- 
fectly anesthetize  the  part  and  any  amount  of  manipulation 
or  cutting  can  be  done  without  inflicting  the  least  pain. 

U      Cocaine  Hydrochlorate    gr.  iss. 

Morphine    Sulphate    gr.  ss. 

Sodium  Chloride   gr.  iij. 

Acid  Boracic   gr.  v. 

Aqua  Destil    fl.  5  iiiss. 

Mix. 

In  using  this  and  similar  solutions,  remember  that  it  is 
not  to  be  injected  under  the  skin,  but  into  the  skin,  just 
below  the  epidermis.  Less  than  a  minim  of  the  fluid  so 
injected  produces  a  white  welt,  about  ^4  incn  in  diameter, 
which  indicates  complete  anesthesia  of  the  part  thus 
blanched.  Injections  are  continued  until  the  surface  to  be 
operated  upon  is  entirely  devoid  of  sensibility.  If  thrown 
into  the  skin,  where  the  peripheral  sensory  nerves  terminate, 
they  are  immediately  paralyzed  by  absorbing  it. 

Twelve  hours  before  the  operation,  administer  one  to 
two  teaspoonfuls  of  sodium  phosphate  in  a  pint  of  warm 
water  so  as  to  move  the  bowels  freely  before  operating. 
Proper  antiseptic  precautions  are  to  be  used  throughout,  of 
course.  No  special  after  treatment  or  further  operative 
measures  are  necessary,  even  in  the  worst  cases,  although  it 
is  best  for  the  patient  to  be  quiet  for  a  day  or  so.  The  wound, 
which  gives  no  further  trouble  and  speedily  closes,  must  be 
kept  scrupulously  clean  by  frequent  changes  of  dry  absorb- 


HEMORRHOIDS DR.    WILLIAMS.  357 

ent  dressings.  After  the  operation,  the  patient  is  to  use  the 
sodium  phosphate  every  morning  before  breakfast,  to  unload 
the  portal  system,  until  the  cure  is  complete,  usually  in  ten 
to  fourteen  days.  The  same  object  can  be  attained  by  the 
use  of  the  following  preparation : 

I£     Flowers  of  Sulphur, 

Cream  of  Tartar, 

Powdered  Sugar equal  parts  by  weight. 

Mix.  One  or  two  teaspoonfuls  in  a  glass  of  water 
before  breakfast. 

The  above  is  the  formula  of  an  English  itinerant  doctor, 
who  travelled  about  the  country  several  years  ago,  and 
acquired  a  great  reputation  for  his  wonderful  success  in 
speedily  relieving  and  permanently  curing  the  worst  cases 
of  piles.  I  have  frequently  prescribed  it  myself  for  internal 
or  bleeding  piles,  and  can  testify  to  its  intrinsic  merits  in 
both  acute  and  chronic  cases. 


35  S 

The  Albright  Wire   Spring  Truss. 

Manufactured  from  Highest  Grade  Material  Only. 
Equipped  with  any  St}de  of  Pads,  Single  or  Double,  Right 
or  Left.     Sizes,  30  to  44. 


The  following  prices  are  Net,  F.  O.  B.,  Philadelphia, 
Pa.,  in  lots  of  One  Dozen  or  Less.  Orders  for  One  Dozen 
or  More,  will  be  shipped  Prepaid  any  where  in  the  U.  S. 

Single  Trusses. 

No.    1.     Hard  Rubber  Front  Pad,  Hard  Rubber 

Ball  and  Socket  Rear  Pad  .    .  Perdoz.,  $21x0 

No.   2.     Kid  Water  Front  Pad,  Hard   Rubber 

Ball  and  Socket  Rear  Pad  .    .Perdoz.,     22.80 

No.   3.     Kid  Water  Front   Pad,   Kid  Eall  and 

Socket  Rear  Pad      .....  Per  doz.,     24.60 

No.  4.  Automatic  Spring  Front  Pad, Hard  Rub- 
ber Ball  and  Socket  Rear  Pad,  Perdoz.,     31.80 

No.   5.     Automatic  Spring  Front  Pad,  Kid  Ball 

and  Socket  Rear  Pad      .    .    .  Perdoz.,     33.60 


Double  Trusses. 

Any  of  the  above  combinations  will    be   supplied   at 
Double  the  Price  of  the  Single  Truss. 


The  "  BILTWELL  "  Truss,  a  New  Style  Wire  Spring 
Truss,  encircles  the  body  similar  to  the  old  style  steel  band 
spring  truss,  but  more  desirable  and  more  comfortable. 
With  Hard  Rubber  Pads    .    .    .    .Perdoz.,  $42.00 
With  Automatic  Spring  Pads 63.60 


Wire  Spring  Trusses  should  retail  at  $5.00  to  $6.00  for 
Single,  and  S10.00  to  S12.00  for  Double. 

The  circumference  of  the  patient's  body,  on  a  line  with 
the  hernia,  is  the  size  of  the  truss  required. 


359 


INDEX. 


Abscess,  Rectal  47 

Acid  Carbolic,  Uses  of 295 

in    hemorrhoids    .  . .' 23 

addiction- 
Cocaine  162 

DlONIN    176 

Double  176 

Drug 162 

Morphine   162 

Opium 162 

Tobacco    ." : 242 

Alcoholism,  Acute 241 

Chronic    ". 211 

ALOPECIA 282 

Treatment , 283 

ANAL  DISEASES 74 

"        Eczema 80 

"        Fissure   57 

Fistula 45 

"        Pruritus 74 

Anesthesia,  Local Si-    83 

Anus,   Diseases   of 74 

Applicateur,  Urethral 343 

Armstrong's  Vril  325 

Baldness 282 

Bed  Wetting 286 

Boils,  To  abort , 297 

Brinkerhoff's   Speculum 19 

"  Rectal  Treatment 323 

CANCER 137 

Causes — 

Predisposing    138 

Primary 137 

Traumatic   139 

Diagnosis  140 

Differential 141 

Pathology  139 


360  INDEX. 

Remedies — 

Arsenious  Acid   146 

Formulae   147-  150 

Protonuclein   158 

Sodium  Ethylate  160 

A^egetable 155-  157 

Zinc  Salts 150 

Formulae    151-  155 

Treatment 142 

Caustic  144 

Constitutional    143 

Internal 157 

Local    143-  144 

Varieties — 

Carcinoma  Cutis  141 

Deep-Seated   141 

Papillomatous 141 

Superficial   140 

Carbolic  Acid,  Uses  of 295 

Antidotes  for  297 

CATARRH,  NASAL  249 

Acute  Rhinitis  250 

Treatment  251 

Chronic  Rhinitis  253 

Atrophic 260 

Treatment   261 

Hypertrophic    256 

Treatment   257 

Simple    253 

Treatment   254 

Cautery,  Solar  292 

Chloral-Camphor  299 

Cigarette  Cure 309 

COCAINE  SOLUTIONS 81 

Schleich  Formulae  82 

"  Modified  356 

With    Suprarenal   Extract 83 

Coffey's  Rectal  System 321 

Colon,  Flushing  the ! 92 


INDEX.  361 

CONSTIPATION  87 

Enemas  91 

Flushing  the  Colon 92 

DILATATION  OF  THE  SPHINCTERS 69 

"             without  Anesthesia  71 

"             in  Fissure  62 

Dilators,  Rectal  73 

"         Vaginal   275-  276 

diseases- 
anal  7  A 

Genito-Urinary  329 

Rectal  7 

Of  Women  270 

DRUG  ADDICTION  162 

Abstinence  Symptoms 171 

Treatment  of  172 

Dionin 176 

Double  Addiction  176 

Treatment  of  176 

Heroin   176 

Modes  of  Withdrawal. 167 

Gradual  Reduction  167 

Rapid  Reduction  17° 

Sudden  Withdrawal  169 

Relapses  206 

Treatment  164 

Diet  during 208 

Exercise  during 179 

Preparatory   177 

Triumph   System    3°7 

Typical   Methods    180 

Forty-Eight  Hour  Cure 190 

Gradual  Reduction 181,  184.  187,  197 

Mattison  Method   201 

Rapid  Reduction  ' 194 

DRUGS  USED   301 

ECZEMA,  ANAL  80 

Treatment  80 

Enemas  91 

ENURESIS  286 

Examination,  Rectal 16 

Felon,  Lancing  a 297 

Fibroma,  Nasal  267 


362  INDEX. 

FISSURE,  ANAL  and  RECTAL 57 

Diagnosis   57 

Symptoms   57 

Treatment 58 

Agnew's 60 

Dilatation   of    Sphincters 62 

Local 58 

Monroe's    59 

FISTULA,  ANAL  and  RECTAL 45 

Cause  0?  45 

;  Classification  oe 45 

Diagnosis  46 

.  Symptoms    46 

Treatment  , 48 

Candler's 50 

Constitutional 56 

Ligature    : 49 

.    Local 52 

Mason's 55 

Surgical    «...     48 

Varieties 45 

Flexible  Splints 298 

Fluids — 

Hemorrhoidal   26,  32,  321,  323 

Hernial   109,  128,  318,  320 

Flushing  the  Colon '. 92 

GENITO-URINARY  DISEASES 329 

Hydrocele 287,  353 

Prostatic  Diseases 329 

Congestion,  Acute 333 

Hyperesthesia 332 

Hypertrophy •••,■•• 330 

Prostatitis,  Chronic 331 

Urethral  Diseases 290,  340 

Stricture    290,  345 

Applicateur  343 

Urethritis  291,  344 

Varicocele 289,  349 

GOITRE  244 

Cystic 245 

Vascular    • 245' 

Remedies  for 244,  246 

Treatment .-.  244 

GYNECOLOGY,   Non-Surgical .-. ."...,.  270 


INDEX. 


363 


26 
28 


HEMORRHOIDS    • ■  ■  •   13.  354 

Definition  of  : : ;  I3 

Description  oe   l* 

1 ^ 
Division  of ° 

External  I4,  I5'    3S 

Sub-division  of   . 14 

Internal  ; I4'     IS 

Sub-division  of   

Mixed M 

Injection  of  29 

Carbolic  Acid    • •  •    •     23 

Internal  Hemorrhoids  I& 

External  ••'"'• 

Injection  Fluids  

Agnew's 

Author's    • 2? 

Brinkerhoff's   ......  3  3 

Coffey's    ;■•■ 321 

Eliot's  ;■■    69. 

■     Hoyt's    34 

Mason's ; '   ;     33 

Monroe's 3 

Overall's    : "     33 

Rorick's 34 

Shuford's    •  ■  ■  ■ '     33 

Treatment    • •     ■'•, l6,  355 

After  Injection    •  • 30.  31.    40 

Palliative ;    ;  •  38"     39 

HERNIA 95 

Definition  of   •  •  •  •  ■  ■  • 95 

Inguinal   ■ 95 

Direct   • I23 

Oblique   •  • 

Needle  ■  • 

Syringe 

Treatment • Il6 

Injection  Method • 95 

Directions — 
General    : l5 

Special ,:■:■: I22 

Direct   I24 

Double I21 

Femoral    •  •  : J  * 


122 
102 
102 


364  INDEX. 

Oblique     124 

Umbilical  125 

Rapid  Method 126 

HERNIAL  FLUIDS— 

Excelsior    320 

Fidelity   130 

Heaton's     129 

Ideal   318 

Miller's    131 

Provost's    132 

Robinson's    131 

Souder's    128 

UNIVERSAL  No.  r no 

UNIVERSAL  No.  2 in 

Walling's    130 

Warren's    129 

Heroin  176 

HYDROCELE  287-  353 

Ideal  Hernia  Cure 318 

INEBRIETY   211 

Alcolholism,  Acute  241 

Chronic   211 

Analysis  of  213 

Treatment  215 

Bellevue  Hospital  227 

Gold  Cure  236 

Home  Cure   225 

Ideal   Cure    220 

Institute  Cures   230,  232 

Keeley  Cure   310 

Matchette's  Treatment    238 

Rapid  Method   218 

Secret  Methods  303 

Triumph  System 303 

Inguinal  Hernia 95 

Injection  Treatment — 

Hemorrhoids   16 

Hernia   95 

Instruments,  Nasal   268 

Rectal   84-    86 

Trritable  Ulcer  57 

Keeley  System,  The 310 

Local  Anesthesia  81-    83 

Mandragorne   Fake,   The 316 


INDEX.  365 

MEDICAL  MELANGE 292 

Carbolic  Acid,  Uses  of 295 

Chloral-Camphor    299 

Flexible  Splints  298 

Painless  Tooth  Extraction 299 

Respiratory  Diseases — Remedy  294 

Solar  Cautery  292 

Morphine  Addiction 162 

NASAL  CATARRH   249 

"        Fibroma  ' 267 

Instruments  268 

Polypi    266 

O'Neil's  Speculum  20 

Opium  Addiction  I02 

Polypus,  Nasal 266 

Rectal  66 

PROLAPSE,  RECTAL  63 

Treatment — 

Complete   65 

Partial 64 

Prostatic  Diseases  329 

Pruritus — 

Anal    74 

Treatment   75 

Palliative     yy 

Vulval    277 

RECTAL  DISEASES  7 

Abscess   47 

Dilatation    69,  71 

Dilators   y^ 

Examination     16 

Fissure    '. 57 

Fistula   45 

Instruments 84-  86 

Polypus   66 

Prolapse  63 

Reflexes   67 

Specula    IQ-  2o 

Ulcer  41 

Rsctum,    Diseases   of 7 

Blood  supply  of. 14 


o 


V>  INDEX. 


Rrflex  Irritation   67 

"        Symptoms  in  Ulcer 41 

Respiratory  Diseases,  Remedy 294 

Rhinitis,  Acute 250 

"        Atrophic    260 

"        Chronic   253 

"        Hypertrophic    256 

SECRET  SYSTEMS  EXPOSED 302 

Armstrong's  Vril  325 

Brinkerhoff's 323 

Coffey's    321 

Excelsior  Hernia  Cure 320 

Ideal  Hernia  Cure 318 

Keeley's    310 

Slandais  Pile 322 

Tri-Elixiria    314 

Triumph  303 

Solar  Cautery  292 

Speculum,  Brinkerhoff's 19 

"  O'Neil's    20 

Pratt's  Dilating  73 

Sphincters,  Dilatation  of 69 

Splints,  Flexible  298 

Spray,  Niagara ,. 275-  276 

Stricture,  Urethral  290,  345 

Swindle,  The  Husa 317 

Systems,  Secret 302 

TAPE  WORMS   278 

TOBACCO  ADDICTION   242 

Treatment   242-  243 

KEELEY  Remedy   313 

Triumph  Remedy  308 

Tooth   Extraction — Painless 299 

Tri-Elixiria 314 

TRUSSES 103,  133 

Fitting  of 133 

Illustration  of 106 

Pads  for 105 

"      selection    of 134 

"      size  of  135 

Why  They  Fail 134 

Price-Ltst  of 358 


INDEX.  367 

ULCER- 
irritable  57 

Rectal  41 

Examination  for  42 

Symptoms  of   41 

Treatment  42 

Home    43 

Office    43 

Urethral  Diseases '. 290,  340 

Stricture  290,  345 

Vaginae  Dilators  275-  276 

"        Pruritus  277 

Varicocele   289,  349 

Vril,    Armstrong's 325 


